Provider Demographics
NPI:1396848347
Name:BOYLES, JODY H (DDS)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:H
Last Name:BOYLES
Suffix:
Gender:F
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:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-0399
Mailing Address - Country:US
Mailing Address - Phone:304-265-0312
Mailing Address - Fax:304-265-0314
Practice Address - Street 1:711 N PIKE ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1221
Practice Address - Country:US
Practice Address - Phone:304-265-4600
Practice Address - Fax:304-265-6008
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4001010-000Medicaid