Provider Demographics
NPI:1194350975
Name:BOLDEN, KORYNN L (RDH)
Entity type:Individual
Prefix:
First Name:KORYNN
Middle Name:L
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11324 WAGON PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79934-3373
Mailing Address - Country:US
Mailing Address - Phone:915-504-8860
Mailing Address - Fax:
Practice Address - Street 1:11324 WAGON PL
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79934-3373
Practice Address - Country:US
Practice Address - Phone:915-504-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20637124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist