Provider Demographics
NPI:1821178609
Name:BOLTZ, SCOTT BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:BRIAN
Last Name:BOLTZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1182 N 850 EAST
Mailing Address - Street 2:
Mailing Address - City:GREENTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46936-8828
Mailing Address - Country:US
Mailing Address - Phone:765-628-3204
Mailing Address - Fax:765-864-2328
Practice Address - Street 1:604 E BOULEVARD ST.
Practice Address - Street 2:SUITE B
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-2286
Practice Address - Country:US
Practice Address - Phone:765-864-2328
Practice Address - Fax:765-864-2333
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008297A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice