Provider Demographics
NPI:1205136785
Name:BOLTON, LAUREN MICHELLE (DMD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELLE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MICHELLE
Other - Last Name:BOLTON-GILICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:1708 E PASS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3528
Mailing Address - Country:US
Mailing Address - Phone:228-822-9190
Mailing Address - Fax:228-822-9559
Practice Address - Street 1:1708 E PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3528
Practice Address - Country:US
Practice Address - Phone:228-822-9190
Practice Address - Fax:228-822-9559
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3546-10122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist