Provider Demographics
NPI:1497833552
Name:BOLT, RAYMOND L (DMD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:L
Last Name:BOLT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 OPELIKA ROAD
Mailing Address - Street 2:SUITE 6-167
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830
Mailing Address - Country:US
Mailing Address - Phone:334-466-9970
Mailing Address - Fax:334-466-8915
Practice Address - Street 1:1550 OPELIKA ROAD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830
Practice Address - Country:US
Practice Address - Phone:334-466-9970
Practice Address - Fax:334-466-8915
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL33151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009973950Medicaid
90955Medicare UPIN