Provider Demographics
NPI:1063490118
Name:BOOTH, MICHAEL JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32560 UTICA RD
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-2215
Mailing Address - Country:US
Mailing Address - Phone:586-293-8530
Mailing Address - Fax:586-293-6539
Practice Address - Street 1:32560 UTICA RD
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026-2215
Practice Address - Country:US
Practice Address - Phone:586-293-8530
Practice Address - Fax:586-293-6539
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-08
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI131251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice