Provider Demographics
NPI:1235140013
Name:DR. MARK BOECHE D.D.S. INC.
Entity Type:Organization
Organization Name:DR. MARK BOECHE D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOECHE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-754-5768
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33471100Medicaid