Healthcare Provider Details

I. General information

NPI: 1174751838
Provider Name (Legal Business Name): BOLTON GENERAL & COSMETIC DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 04/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 MAIN ST
BOLTON MA
01740-1300
US

IV. Provider business mailing address

563 MAIN ST
BOLTON MA
01740-1300
US

V. Phone/Fax

Practice location:
  • Phone: 978-779-2888
  • Fax: 978-779-6023
Mailing address:
  • Phone: 978-779-2888
  • Fax: 978-779-6023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19804
License Number StateMA

VIII. Authorized Official

Name: AMPARO M DAVID
Title or Position: OWNER
Credential: DMD
Phone: 978-779-2888