Provider Demographics
NPI:1184816936
Name:BOOTH, JOSEPH JUSTIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JUSTIN
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WILDROSE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:IA
Mailing Address - Zip Code:52228-7603
Mailing Address - Country:US
Mailing Address - Phone:512-784-9961
Mailing Address - Fax:
Practice Address - Street 1:715 BLUEGRASS CIR
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-7978
Practice Address - Country:US
Practice Address - Phone:319-266-3545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195043810Medicaid