Provider Demographics
NPI:1578502878
Name:BOOZER, KENT B (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:B
Last Name:BOOZER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:KENT
Other - Middle Name:B
Other - Last Name:BOOZER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:117 LINDSEY LN
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1633
Mailing Address - Country:US
Mailing Address - Phone:903-596-8978
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:75703-1633
Practice Address - Country:US
Practice Address - Phone:903-597-2121
Practice Address - Fax:903-581-7776
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009556401Medicaid
TXU96904Medicare UPIN
TX8B1693Medicare ID - Type Unspecified