Provider Demographics
NPI:1558665273
Name:BULLOCK, CAROLYN DEOLINDA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:DEOLINDA
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:CAROLYN
Other - Middle Name:DEOLINDA
Other - Last Name:BOETTGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:P.O. BOX 69
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:CO
Mailing Address - Zip Code:80530
Mailing Address - Country:US
Mailing Address - Phone:303-833-3230
Mailing Address - Fax:303-833-4477
Practice Address - Street 1:320 5TH ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:CO
Practice Address - Zip Code:80530
Practice Address - Country:US
Practice Address - Phone:303-833-3230
Practice Address - Fax:303-833-4477
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD078361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice