Provider Demographics
NPI:1497920656
Name:JOHANBOEKE, MILTON FREDERICK JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:MILTON
Middle Name:FREDERICK
Last Name:JOHANBOEKE
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 CLIFTY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-1614
Mailing Address - Country:US
Mailing Address - Phone:812-273-0207
Mailing Address - Fax:
Practice Address - Street 1:1105 CLIFTY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-1614
Practice Address - Country:US
Practice Address - Phone:812-273-0207
Practice Address - Fax:812-273-3366
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010214A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice