Provider Demographics
NPI:1609485432
Name:AMETHYST DENTAL CARE LLC
Entity Type:Organization
Organization Name:AMETHYST DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOEKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-288-9288
Mailing Address - Street 1:1751 HIGHWAY 52 N
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-1692
Mailing Address - Country:US
Mailing Address - Phone:507-282-9288
Mailing Address - Fax:507-292-6622
Practice Address - Street 1:1751 HIGHWAY 52 N
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1692
Practice Address - Country:US
Practice Address - Phone:507-282-9288
Practice Address - Fax:507-292-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1841286457OtherNPI
MN1720073554OtherNPI