Provider Demographics
NPI:1104007996
Name:DEBORA A. BOLTON, DDS, PA
Entity Type:Organization
Organization Name:DEBORA A. BOLTON, DDS, PA
Other - Org Name:WILLOWDAILE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-479-5800
Mailing Address - Street 1:3823 GUESS RD
Mailing Address - Street 2:SUITE P
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-1505
Mailing Address - Country:US
Mailing Address - Phone:919-479-5800
Mailing Address - Fax:919-620-9244
Practice Address - Street 1:3823 GUESS RD
Practice Address - Street 2:SUITE P
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-1505
Practice Address - Country:US
Practice Address - Phone:919-479-5800
Practice Address - Fax:919-620-9244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC72511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900493Medicaid