Provider Demographics
NPI:1053545707
Name:BOLTEN, THOMAS RICHARD (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RICHARD
Last Name:BOLTEN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
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Mailing Address - Street 1:6022 W MAPLE RD STE 405
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4408
Mailing Address - Country:US
Mailing Address - Phone:248-855-2006
Mailing Address - Fax:248-855-0571
Practice Address - Street 1:6022 W MAPLE RD STE 405
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4408
Practice Address - Country:US
Practice Address - Phone:248-855-2006
Practice Address - Fax:248-855-0571
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI29010201761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery