Provider Demographics
NPI:1457445314
Name:BOOTH, STEPHEN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:C
Last Name:BOOTH
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 1:5954 HARBOUR PARK DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2163
Mailing Address - Country:US
Mailing Address - Phone:804-739-1600
Mailing Address - Fax:804-739-9035
Practice Address - Street 1:5954 HARBOUR PARK DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2163
Practice Address - Country:US
Practice Address - Phone:804-739-1600
Practice Address - Fax:804-739-9035
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014110241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11024OtherDELTA DENTAL PROVIDER NO.
VA182419OtherANTHEM PROVIDER NO.
VA9179964Medicaid