Provider Demographics
NPI:1508924739
Name:JOHN K BOEDIGHEIMER DDS INC
Entity Type:Organization
Organization Name:JOHN K BOEDIGHEIMER DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF JOHN K BOEDIGHEIMER DD
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KENNEDY
Authorized Official - Last Name:BOEDIGHEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-492-9983
Mailing Address - Street 1:1445 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-1782
Mailing Address - Country:US
Mailing Address - Phone:937-492-9983
Mailing Address - Fax:937-492-8869
Practice Address - Street 1:1445 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-1782
Practice Address - Country:US
Practice Address - Phone:937-492-9983
Practice Address - Fax:937-492-8869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14422122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0271496Medicaid