MEDICARE: DR. KENNETH ANTHONY BOLIN D.D.S.

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	122300000X	Dentist	12794	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255334140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH ANTHONY BOLIN D.D.S.

Provider Business Mailing Address
First Line	:	14335 REGENCY PL
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75254-8509
Country	:	US
Telephone Number	:	972-716-9787
Fax Number	:	972-716-9787

Provider Business Practice Location Address
First Line	:	14335 REGENCY PL
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75254-8509
Country	:	US
Telephone Number	:	972-716-9787
Fax Number	:	972-716-9787

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	08/12/2014

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