Provider Demographics
NPI:1619907474
Name:BOONE, JACK LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LEE
Last Name:BOONE
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 1:212 AINSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:HERTFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27944-1400
Mailing Address - Country:US
Mailing Address - Phone:252-426-5585
Mailing Address - Fax:252-426-5766
Practice Address - Street 1:212 AINSLEY AVE
Practice Address - Street 2:
Practice Address - City:HERTFORD
Practice Address - State:NC
Practice Address - Zip Code:27944-1400
Practice Address - Country:US
Practice Address - Phone:252-426-5585
Practice Address - Fax:252-426-5766
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990862Medicaid
NC90862OtherBCBS PROVIDER ID
NC20-2096412OtherFEDERAL EIN