Provider Demographics
NPI:1063188761
Name:BOLAND, DANIEL EARL (DMD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:EARL
Last Name:BOLAND
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 1:121 NEWMAN DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3528
Mailing Address - Country:US
Mailing Address - Phone:618-727-9044
Mailing Address - Fax:
Practice Address - Street 1:2817 REILLY ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7324
Practice Address - Country:US
Practice Address - Phone:910-907-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019033367122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist