Provider Demographics
NPI:1013171438
Name:BOLDEN, SHALETHA M (DDS, MSD)
Entity Type:Individual
Prefix:
First Name:SHALETHA
Middle Name:M
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 RIVERSTONE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:770-479-0600
Mailing Address - Fax:
Practice Address - Street 1:1425 RIVERSTONE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5611
Practice Address - Country:US
Practice Address - Phone:770-479-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX277901223E0200X
TN88021223E0200X
GADN0154291223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics