Provider Demographics
NPI:1487092029
Name:BOLIN, JAMES TYLER (DMD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:TYLER
Last Name:BOLIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 RUCCIO WAY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3584
Mailing Address - Country:US
Mailing Address - Phone:859-309-1095
Mailing Address - Fax:
Practice Address - Street 1:220 RUCCIO WAY
Practice Address - Street 2:SUITE 120
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3584
Practice Address - Country:US
Practice Address - Phone:859-309-1095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9639122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program