Provider Demographics
NPI:1487867990
Name:BOLING, GARY WAYNE (DDS)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:BOLING
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 1:1119 COBBLE WAY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-3071
Mailing Address - Country:US
Mailing Address - Phone:714-357-5353
Mailing Address - Fax:
Practice Address - Street 1:228 HAMILTON CROSSING DR
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2262
Practice Address - Country:US
Practice Address - Phone:714-357-5353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA234801223G0001X
TN122991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice