Provider Demographics
NPI:1386754620
Name:BOLES, JENNIFER NEWTON (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:NEWTON
Last Name:BOLES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4279 HWY 15
Mailing Address - Street 2:
Mailing Address - City:MANGHAM
Mailing Address - State:LA
Mailing Address - Zip Code:71259
Mailing Address - Country:US
Mailing Address - Phone:318-248-4986
Mailing Address - Fax:318-248-3379
Practice Address - Street 1:4279 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:MANGHAM
Practice Address - State:LA
Practice Address - Zip Code:71259-5189
Practice Address - Country:US
Practice Address - Phone:318-248-4986
Practice Address - Fax:318-248-3379
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA50501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1850501Medicaid
LA5050OtherSTATE LICENSE #