Provider Demographics
NPI:1518515378
Name:BOLLING, LEAH A
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:A
Last Name:BOLLING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186A TWOMBLEY RD APT A
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-4056
Mailing Address - Country:US
Mailing Address - Phone:207-329-7271
Mailing Address - Fax:
Practice Address - Street 1:19 PETTINGILL ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5903
Practice Address - Country:US
Practice Address - Phone:207-513-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERDH4143124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist