Provider Demographics
NPI:1164892352
Name:BOLD DENTAL POTTSVILLE
Entity Type:Organization
Organization Name:BOLD DENTAL POTTSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRANSITION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDUTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-436-0518
Mailing Address - Street 1:7146 SR 247
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72858-8891
Mailing Address - Country:US
Mailing Address - Phone:479-858-7382
Mailing Address - Fax:
Practice Address - Street 1:7146 SR 247
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72858-8891
Practice Address - Country:US
Practice Address - Phone:479-858-7382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOLD DENTAL PARTNERS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty