Provider Demographics
NPI:1578501144
Name:BOUGHAN, BARRY BOOTH (DDS)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:BOOTH
Last Name:BOUGHAN
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 1:485 S DOBSON RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5602
Mailing Address - Country:US
Mailing Address - Phone:623-434-9343
Mailing Address - Fax:623-321-6268
Practice Address - Street 1:1904 W PARKSIDE LN
Practice Address - Street 2:SUITE 201
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-1228
Practice Address - Country:US
Practice Address - Phone:623-434-9343
Practice Address - Fax:623-321-6268
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD65531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ988959Medicaid