Provider Demographics
NPI:1225232176
Name:JOSEPH R. BOULTER, D.M.D., M.A.G.D., P.A.
Entity Type:Organization
Organization Name:JOSEPH R. BOULTER, D.M.D., M.A.G.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BOULTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-731-0432
Mailing Address - Street 1:8823 GOODBYS EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4691
Mailing Address - Country:US
Mailing Address - Phone:904-731-0432
Mailing Address - Fax:904-731-5755
Practice Address - Street 1:8823 GOODBYS EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4691
Practice Address - Country:US
Practice Address - Phone:904-731-0432
Practice Address - Fax:904-731-5755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty