Provider Demographics
NPI:1386663128
Name:BOETCHER, CHARLES J (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:BOETCHER
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 1:520 W LEOTA ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6581
Mailing Address - Country:US
Mailing Address - Phone:308-532-3868
Mailing Address - Fax:308-532-3811
Practice Address - Street 1:520 W LEOTA ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6581
Practice Address - Country:US
Practice Address - Phone:308-532-3868
Practice Address - Fax:308-532-3811
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4679122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist