Provider Demographics
NPI:1609471895
Name:TERRY L BOONE DDS, PA
Entity Type:Organization
Organization Name:TERRY L BOONE DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:870-267-1423
Mailing Address - Street 1:7197 SHERIDAN RD STE 115
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-3261
Mailing Address - Country:US
Mailing Address - Phone:870-267-1423
Mailing Address - Fax:870-267-1424
Practice Address - Street 1:7197 SHERIDAN RD STE 115
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-3261
Practice Address - Country:US
Practice Address - Phone:870-267-1423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-03
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102144608Medicaid