Provider Demographics
NPI:1073819991
Name:BOLEN FAMILY DENTISTRY P.C.
Entity Type:Organization
Organization Name:BOLEN FAMILY DENTISTRY P.C.
Other - Org Name:FAMILY DENTISTRY OF SIOUX FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-261-6488
Mailing Address - Street 1:3508 S MINNESOTA AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3508 S MINNESOTA AVE STE 108
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6455
Practice Address - Country:US
Practice Address - Phone:605-339-0219
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD0926261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental