Provider Demographics
NPI:1811622525
Name:BOLIVAR SMILES DENTISTRY, LLC
Entity Type:Organization
Organization Name:BOLIVAR SMILES DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:GUERRA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:417-326-3537
Mailing Address - Street 1:1300 N OAKLAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3008
Mailing Address - Country:US
Mailing Address - Phone:417-326-6061
Mailing Address - Fax:417-326-3537
Practice Address - Street 1:1300 N OAKLAND AVE STE B
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3008
Practice Address - Country:US
Practice Address - Phone:417-326-6061
Practice Address - Fax:417-326-3537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14888370OtherCAQH NUMBER
MO2009015933OtherSTATE LINCENSE
B6987876OtherDEA