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General NPI Number Information
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NPI Number | 1396363602
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Entity Type | Individual
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Provider Name | JUSTINA ARDOIN BOLES DMD
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Gender | Female
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Dates
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Enumeration Date | 07/13/2020
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Last Update Date | 07/13/2020
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Provider Practice Location Address
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Address Line | 1911 SKYLAND BLVD E STE A3
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City | TUSCALOOSA
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State | AL
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Zip | 35405-5865
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Country | US
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Telephone | 205-267-5985
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Fax |
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Provider Business Mailing Address
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Address Line | 180 ROSCOMMON RD
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City | TUSCALOOSA
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State | AL
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Zip | 35405-6126
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Country | US
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Telephone | 601-794-7844
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D.0006791-C1
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License Number State | AL
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