Provider Demographics
NPI:1659962595
Name:BOLEN DENTAL PC
Entity Type:Organization
Organization Name:BOLEN DENTAL PC
Other - Org Name:CUSTER DENTAL STUDIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT BOLEN DENTAL PC
Authorized Official - Prefix:DR
Authorized Official - First Name:KARI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-261-6488
Mailing Address - Street 1:141 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CUSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57730-1528
Mailing Address - Country:US
Mailing Address - Phone:605-261-6488
Mailing Address - Fax:
Practice Address - Street 1:141 N 5TH ST
Practice Address - Street 2:
Practice Address - City:CUSTER
Practice Address - State:SD
Practice Address - Zip Code:57730-1528
Practice Address - Country:US
Practice Address - Phone:605-321-2086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental