MEDICARE: JIMMY CARROLL BOLEY D.D.S., M.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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	7425	TX

General Provider Information

NPI Number	:	1396154936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIMMY CARROLL BOLEY D.D.S., M.S.

Provider Business Mailing Address
First Line	:	1106 HIGH VISTA LN
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-1520
Country	:	US
Telephone Number	:	972-808-0221
Fax Number	:

Provider Business Practice Location Address
First Line	:	1106 HIGH VISTA LN
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-1520
Country	:	US
Telephone Number	:	972-808-0221
Fax Number	:

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

Provider Enumeration Date	:	08/07/2014
Last Update Date	:	08/07/2014

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