Provider Demographics
NPI:1871954479
Name:BLAIRSVILLE DENTISTRY, LLC
Entity type:Organization
Organization Name:BLAIRSVILLE DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-781-3340
Mailing Address - Street 1:10 DEER CROSSING TRCE
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-1496
Mailing Address - Country:US
Mailing Address - Phone:706-781-3340
Mailing Address - Fax:
Practice Address - Street 1:10 DEER CROSSING TRCE
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-1496
Practice Address - Country:US
Practice Address - Phone:706-781-3340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0125421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty