Provider Demographics
NPI:1598741779
Name:BOONE, MARK (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BOONE
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USNDC FAR EAST
Mailing Address - Street 2:PSC 475 BOX 1857
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350
Mailing Address - Country:JP
Mailing Address - Phone:0118146-816-8808
Mailing Address - Fax:
Practice Address - Street 1:USNDC FAR EAST
Practice Address - Street 2:PSC 475 BOX 1857
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96350
Practice Address - Country:JP
Practice Address - Phone:0118146-816-8808
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74901223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7490Medicare UPIN