Provider Demographics
NPI:1073067328
Name:BOOE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BOOE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:BOOE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:812-847-5101
Mailing Address - Street 1:1206 N 1000 W
Mailing Address - Street 2:SUITE A
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-9696
Mailing Address - Country:US
Mailing Address - Phone:812-847-5101
Mailing Address - Fax:
Practice Address - Street 1:1206 N 1000 W
Practice Address - Street 2:SUITE A
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-9696
Practice Address - Country:US
Practice Address - Phone:812-847-5101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012174A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental