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General NPI Number Information
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NPI Number | 1962623819
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Entity Type | Individual
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Provider Name | J. SPENCER BOLEY D.M.D
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Gender | Male
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 09/28/2010
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Provider Practice Location Address
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Address Line | 4501 W WEDGE DR
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City | FAYETTEVILLE
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State | AR
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Zip | 72704-7532
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Country | US
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Telephone | 502-468-3170
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Fax |
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Provider Business Mailing Address
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Address Line | 4501 W WEDGE DR
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City | FAYETTEVILLE
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State | AR
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Zip | 72704-7532
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Country | US
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Telephone | 502-468-3170
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 3784
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License Number State | AR
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