Provider Demographics
NPI:1194357418
Name:BOLTON LAKE DENTAL LLC
Entity type:Organization
Organization Name:BOLTON LAKE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ILIES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-646-3003
Mailing Address - Street 1:1120 BOSTON TPKE
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:CT
Mailing Address - Zip Code:06043-7439
Mailing Address - Country:US
Mailing Address - Phone:860-646-3003
Mailing Address - Fax:
Practice Address - Street 1:1120 BOSTON TPKE
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:CT
Practice Address - Zip Code:06043-7439
Practice Address - Country:US
Practice Address - Phone:860-646-3003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental