Provider Demographics
NPI:1730219783
Name:BOLTON, LUTHER JACK (DDS MSD)
Entity type:Individual
Prefix:DR
First Name:LUTHER
Middle Name:JACK
Last Name:BOLTON
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:DR
Other - First Name:L
Other - Middle Name:JACK
Other - Last Name:BOLTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS MSD
Mailing Address - Street 1:1151 N BUCKNER BLVD
Mailing Address - Street 2:SUITE 406
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-3425
Mailing Address - Country:US
Mailing Address - Phone:214-328-6354
Mailing Address - Fax:214-327-7088
Practice Address - Street 1:1151 N BUCKNER BLVD
Practice Address - Street 2:SUITE 406
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3425
Practice Address - Country:US
Practice Address - Phone:214-328-6354
Practice Address - Fax:214-327-7088
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002685L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery