MEDICARE: BOLINGER DENTAL L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1114418654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLINGER DENTAL L.L.C.

Provider Business Mailing Address
First Line	:	5800 FAIRFIELD AVE.
Second Line	:	SUITE 220
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-3417
Country	:	US
Telephone Number	:	260-456-6073
Fax Number	:	260-744-9251

Provider Business Practice Location Address
First Line	:	5800 FAIRFIELD AVE.
Second Line	:	SUITE 220
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-3417
Country	:	US
Telephone Number	:	260-456-6073
Fax Number	:	260-744-9251

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. CRAIG BOLINGER
Credential	:	DDS
Telephone Number	:	260-456-6073

Provider Enumeration Date	:	05/21/2018
Last Update Date	:	05/21/2018

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