Provider Demographics
NPI:1811099930
Name:BOLAND, WILLIAM TILDEN III (DMD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:TILDEN
Last Name:BOLAND
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5700 OLD RICHMOND AVENUE
Mailing Address - Street 2:SUITE D15
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1828
Mailing Address - Country:US
Mailing Address - Phone:804-288-4103
Mailing Address - Fax:804-288-4505
Practice Address - Street 1:5700 OLD RICHMOND AVENUE
Practice Address - Street 2:SUITE D15
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1828
Practice Address - Country:US
Practice Address - Phone:804-288-4103
Practice Address - Fax:804-288-4505
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010078001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
101562OtherANTHEM
783066OtherUNITED CONCORDIA