Healthcare Provider Details

I. General information

NPI: 1518515378
Provider Name (Legal Business Name): LEAH A BOLLING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 PETTINGILL ST
LEWISTON ME
04240-5903
US

IV. Provider business mailing address

186A TWOMBLEY RD APT A
SANFORD ME
04073-4056
US

V. Phone/Fax

Practice location:
  • Phone: 207-513-1111
  • Fax:
Mailing address:
  • Phone: 207-329-7271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH4143
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: