Provider Demographics
NPI:1447387741
Name:BOLIN, DANITA ANTIONETTE (DDS)
Entity Type:Individual
Prefix:
First Name:DANITA
Middle Name:ANTIONETTE
Last Name:BOLIN
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 1:204 MILLFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5085
Mailing Address - Country:US
Mailing Address - Phone:817-490-1817
Mailing Address - Fax:
Practice Address - Street 1:6801 MCCART AVE STE B2
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-6368
Practice Address - Country:US
Practice Address - Phone:817-423-9300
Practice Address - Fax:817-423-9097
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice