Provider Demographics
NPI:1336202951
Name:LUPERON, BOLIVAR
Entity Type:Individual
Prefix:DR
First Name:BOLIVAR
Middle Name:
Last Name:LUPERON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 HAMILTON MILL RD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4187
Mailing Address - Country:US
Mailing Address - Phone:770-932-8577
Mailing Address - Fax:
Practice Address - Street 1:2725 HAMILTON MILL RD
Practice Address - Street 2:SUITE 700
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4187
Practice Address - Country:US
Practice Address - Phone:770-932-8577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0132141223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0700XDental ProvidersDentistProsthodontics