Provider Demographics
NPI:1508046129
Name:KENT B BOOZER DDS PA
Entity Type:Organization
Organization Name:KENT B BOOZER DDS PA
Other - Org Name:BOOZER DENTAL WORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOOZER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-597-2121
Mailing Address - Street 1:5540 OLD JACKSONVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3378
Mailing Address - Country:US
Mailing Address - Phone:903-597-2121
Mailing Address - Fax:903-581-7776
Practice Address - Street 1:5540 OLD JACKSONVILLE HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3378
Practice Address - Country:US
Practice Address - Phone:903-597-2121
Practice Address - Fax:903-581-7776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty