Provider Demographics
NPI:1902199466
Name:BOULDIEN, GEORGE HOWARD (DDSMS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:HOWARD
Last Name:BOULDIEN
Suffix:
Gender:M
Credentials:DDSMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-7915
Mailing Address - Country:US
Mailing Address - Phone:901-755-3354
Mailing Address - Fax:
Practice Address - Street 1:3100 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-7915
Practice Address - Country:US
Practice Address - Phone:901-755-3354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics