Provider Demographics
NPI:1427185776
Name:RICHARD C BOLTEN DDS PC
Entity Type:Organization
Organization Name:RICHARD C BOLTEN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:BOLTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-673-7026
Mailing Address - Street 1:4721 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3565
Mailing Address - Country:US
Mailing Address - Phone:248-673-7026
Mailing Address - Fax:248-673-6989
Practice Address - Street 1:4721 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3565
Practice Address - Country:US
Practice Address - Phone:248-673-7026
Practice Address - Fax:248-673-6989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010125751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901012575OtherSTATE DENTAL LICENSE