Provider Demographics
NPI:1063678407
Name:BOECHE, MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BOECHE
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 1:1915 E MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-2647
Mailing Address - Country:US
Mailing Address - Phone:608-754-5768
Mailing Address - Fax:608-754-7195
Practice Address - Street 1:1915 E MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-2647
Practice Address - Country:US
Practice Address - Phone:608-754-5768
Practice Address - Fax:608-754-7195
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33471100Medicaid