MEDICARE: DR. CRAIG MATTHEW BOLINGER DDS

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	1223G0001X	General Practice Dentistry	12010634A	IN

General Provider Information

NPI Number	:	1124153325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRAIG MATTHEW BOLINGER DDS

Provider Business Mailing Address
First Line	:	11121 EAGLE RIVER RUN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-8742
Country	:	US
Telephone Number	:	260-484-8490
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 FAIRFIELD AVE
Second Line	:	SUITE 220
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-3400
Country	:	US
Telephone Number	:	260-456-6073
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	04/19/2017

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