Provider Demographics
NPI:1730752098
Name:BOLLER, MATTHEW EMIL (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:EMIL
Last Name:BOLLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:MATTHEW
Other - Middle Name:EMIL
Other - Last Name:BOLLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MATTHEW BOLLER, DMD
Mailing Address - Street 1:14 LOCKWOOD DR STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1126
Mailing Address - Country:US
Mailing Address - Phone:843-258-4306
Mailing Address - Fax:
Practice Address - Street 1:14 LOCKWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1126
Practice Address - Country:US
Practice Address - Phone:843-258-4306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC98331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty