Provider Demographics
NPI:1457323313
Name:BOLTEN, RICHARD CARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CARL
Last Name:BOLTEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3522
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:48329-3522
Practice Address - Country:US
Practice Address - Phone:248-673-7026
Practice Address - Fax:248-673-6989
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010125751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901012575OtherSTATE LICENSE