Provider Demographics
NPI:1205096757
Name:BOLDEN, CHARLES WILLIAM (DMD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:BOLDEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEYERSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15552-1035
Mailing Address - Country:US
Mailing Address - Phone:814-634-0095
Mailing Address - Fax:
Practice Address - Street 1:349 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEYERSDALE
Practice Address - State:PA
Practice Address - Zip Code:15552-1035
Practice Address - Country:US
Practice Address - Phone:814-634-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-028696-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice