Provider Demographics
NPI:1285626598
Name:BOLDS, MONICA LATRISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:LATRISE
Last Name:BOLDS
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 1:2600 MILSCOTT DR APT 1234
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6020
Mailing Address - Country:US
Mailing Address - Phone:917-716-0899
Mailing Address - Fax:
Practice Address - Street 1:2600 MILSCOTT DR APT 1234
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:917-716-0899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9074122300000X
NJ22D1021857001223G0001X
GADN0155021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ731712172OtherTAX IDENTIFICATION