Provider Demographics
NPI:1457193815
Name:BOUSSELOT, COLE (DDS)
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:BOUSSELOT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6841 SUMMERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-6417
Mailing Address - Country:US
Mailing Address - Phone:563-343-1395
Mailing Address - Fax:
Practice Address - Street 1:3520 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1620
Practice Address - Country:US
Practice Address - Phone:563-359-9165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-102121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice