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General NPI Number Information
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NPI Number | 1336202951
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Entity Type | Individual
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Provider Name | DR. BOLIVAR LUPERON
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Gender | Male
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 10/13/2025
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Provider Practice Location Address
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Address Line | 1 W COURT SQ STE 325
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City | DECATUR
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State | GA
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Zip | 30030-2576
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Country | US
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Telephone | 470-568-2781
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Fax |
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Provider Business Mailing Address
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Address Line | 1 W COURT SQ STE 325
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City | DECATUR
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State | GA
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Zip | 30030-2576
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Country | US
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Telephone | 470-568-2781
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | DN013214
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN013214
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License Number State | GA
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