Provider Demographics
NPI:1689749657
Name:BOULDEN, PETER D (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:BOULDEN
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 1:1875 OLD ALABAMA RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2201
Mailing Address - Country:US
Mailing Address - Phone:770-998-3838
Mailing Address - Fax:770-998-3865
Practice Address - Street 1:1875 OLD ALABAMA RD
Practice Address - Street 2:SUITE 130
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2201
Practice Address - Country:US
Practice Address - Phone:770-998-3838
Practice Address - Fax:770-998-3865
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0125421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice