Provider Demographics
NPI:1013023837
Name:BOULDIEN, GREGORY (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:BOULDIEN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9880 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1722
Mailing Address - Country:US
Mailing Address - Phone:662-470-4919
Mailing Address - Fax:662-874-6295
Practice Address - Street 1:9880 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1722
Practice Address - Country:US
Practice Address - Phone:662-470-4919
Practice Address - Fax:662-874-6295
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN52131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics