Provider Demographics
NPI:1831472810
Name:STONEBRIDGE DENTAL
Entity Type:Organization
Organization Name:STONEBRIDGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-547-0554
Mailing Address - Street 1:6633 W ELDORADO PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-6185
Mailing Address - Country:US
Mailing Address - Phone:972-547-0554
Mailing Address - Fax:972-547-4865
Practice Address - Street 1:6633 W ELDORADO PKWY STE 100
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-6185
Practice Address - Country:US
Practice Address - Phone:972-547-0554
Practice Address - Fax:972-547-4865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210141223G0001X
TX210071223G0001X
1223G0001X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty