=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619311198
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOLD DENTAL PARTNERS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2013
-----------------------------------------------------
Last Update Date | 08/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 640 N GARLAND AVE SUITE 104
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-521-2653
-----------------------------------------------------
Fax | 479-575-0380
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1108
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72702-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-439-9192
-----------------------------------------------------
Fax | 479-725-2395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SCOTT L BOLDING
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 479-521-2653
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3062
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------