Healthcare Provider Details

I. General information

NPI: 1063162352
Provider Name (Legal Business Name): JORDAN RANDALL BOLAND DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 W STATE ST
OLEAN NY
14760-1952
US

IV. Provider business mailing address

2108 W STATE ST
OLEAN NY
14760-1952
US

V. Phone/Fax

Practice location:
  • Phone: 716-373-1210
  • Fax:
Mailing address:
  • Phone: 716-373-1210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number063307
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number063307
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: