Provider Demographics
NPI:1790916146
Name:BRANT BOLING, DDS, PLLC
Entity Type:Organization
Organization Name:BRANT BOLING, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-598-0835
Mailing Address - Street 1:1429 CLEAR LAKE RD STE 700
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5805
Mailing Address - Country:US
Mailing Address - Phone:817-598-0835
Mailing Address - Fax:817-598-0845
Practice Address - Street 1:1429 CLEAR LAKE RD STE 700
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5805
Practice Address - Country:US
Practice Address - Phone:817-598-0835
Practice Address - Fax:817-598-0845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0192401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1962664-04Medicaid