Provider Demographics
NPI:1376081588
Name:BOONEVILLE FAMILY DENTAL, PLLC
Entity Type:Organization
Organization Name:BOONEVILLE FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:BORENGASSER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-719-1373
Mailing Address - Street 1:9205 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-7060
Mailing Address - Country:US
Mailing Address - Phone:479-719-1373
Mailing Address - Fax:
Practice Address - Street 1:1057 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72927-3403
Practice Address - Country:US
Practice Address - Phone:479-719-1373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3525122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty