MEDICARE: J.C. BOLEY, D.D.S., M.S., INC.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00C652	OTHER	TX	BCBSINSURANCE PROVIDER #

General Provider Information

NPI Number	:	1760501944
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J.C. BOLEY, D.D.S., M.S., INC.

Provider Business Mailing Address
First Line	:	400 S COTTONWOOD DR
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-5708
Country	:	US
Telephone Number	:	972-231-4896
Fax Number	:	972-994-9747

Provider Business Practice Location Address
First Line	:	400 S COTTONWOOD DR
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-5708
Country	:	US
Telephone Number	:	972-231-4896
Fax Number	:	972-994-9747

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JIMMY CARROLL BOLEY
Credential	:	D.D.S., M.S.
Telephone Number	:	972-231-4896

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	08/22/2020

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