Provider Demographics
NPI:1831370147
Name:DR. DALE E. BOLT DENTISTRY
Entity type:Organization
Organization Name:DR. DALE E. BOLT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:ERSKINE
Authorized Official - Last Name:BOLT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-921-7806
Mailing Address - Street 1:PO BOX 820
Mailing Address - Street 2:1760 MILITARY HIGHWAY SOUTH
Mailing Address - City:HAMILTON
Mailing Address - State:AL
Mailing Address - Zip Code:35570-0820
Mailing Address - Country:US
Mailing Address - Phone:205-921-7806
Mailing Address - Fax:205-921-7806
Practice Address - Street 1:1760 MILITARY HWY SO.
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:AL
Practice Address - Zip Code:35570-0820
Practice Address - Country:US
Practice Address - Phone:205-921-7806
Practice Address - Fax:205-921-7806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3147122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009940088Medicaid
AL009940089Medicaid