Provider Demographics
NPI:1770714818
Name:BOLTON, BENJAMAS W (MT)
Entity type:Individual
Prefix:
First Name:BENJAMAS
Middle Name:W
Last Name:BOLTON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 W 87TH ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-4628
Mailing Address - Country:US
Mailing Address - Phone:913-894-2070
Mailing Address - Fax:913-322-8697
Practice Address - Street 1:10100 W 87TH ST
Practice Address - Street 2:SUITE 116
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-4628
Practice Address - Country:US
Practice Address - Phone:913-894-2070
Practice Address - Fax:913-322-8697
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSTHR-0000767174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist