Provider Demographics
NPI:1396363602
Name:BOLES, JUSTINA ARDOIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTINA
Middle Name:ARDOIN
Last Name:BOLES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 ROSCOMMON RD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-6126
Mailing Address - Country:US
Mailing Address - Phone:601-794-7844
Mailing Address - Fax:
Practice Address - Street 1:1911 SKYLAND BLVD E STE A3
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-5865
Practice Address - Country:US
Practice Address - Phone:205-267-5985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.0006791-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice