Provider Demographics
NPI:1396154936
Name:BOLEY, JIMMY CARROLL (DDS, MS)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:CARROLL
Last Name:BOLEY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 HIGH VISTA LN
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-1520
Mailing Address - Country:US
Mailing Address - Phone:972-808-0221
Mailing Address - Fax:
Practice Address - Street 1:1106 HIGH VISTA LN
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-1520
Practice Address - Country:US
Practice Address - Phone:972-808-0221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics