Provider Demographics
NPI:1225683089
Name:BOLD, ALEXANDRA JEANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:JEANNE
Last Name:BOLD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 WUNDERLIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-2200
Mailing Address - Country:US
Mailing Address - Phone:406-538-2376
Mailing Address - Fax:406-538-3557
Practice Address - Street 1:215 WUNDERLIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-2200
Practice Address - Country:US
Practice Address - Phone:406-538-2376
Practice Address - Fax:406-538-3557
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17432122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist