Healthcare Provider Details

I. General information

NPI: 1619022548
Provider Name (Legal Business Name): MICHAEL LAURENCE BOLDEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 SAINT JAMES PL
BROOKLYN NY
11238-1811
US

IV. Provider business mailing address

136 SAINT JAMES PL
BROOKLYN NY
11238-1811
US

V. Phone/Fax

Practice location:
  • Phone: 718-783-4348
  • Fax: 781-783-4593
Mailing address:
  • Phone: 718-783-4348
  • Fax: 781-783-4593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number040702
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: