Provider Demographics
NPI:1083826390
Name:BOETTCHER, MARK R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:BOETTCHER
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 1:16905 WEST WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5729
Mailing Address - Country:US
Mailing Address - Phone:262-754-4480
Mailing Address - Fax:262-754-4470
Practice Address - Street 1:16905 WEST WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5729
Practice Address - Country:US
Practice Address - Phone:262-754-4480
Practice Address - Fax:262-754-4470
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50019030151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33363900Medicaid