Provider Demographics
NPI:1578295242
Name:BOOTH, MICHELLE AGNES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:AGNES
Last Name:BOOTH
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 1:110 N 127TH ST E APT 1533
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2774
Mailing Address - Country:US
Mailing Address - Phone:435-265-2727
Mailing Address - Fax:
Practice Address - Street 1:10333 E 21ST ST N STE 101
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3544
Practice Address - Country:US
Practice Address - Phone:316-684-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2484122300000X
FLDRPM2484122300000X
KS622281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist