Provider Demographics
NPI:1629205554
Name:BOOTH, MARY K (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:BOOTH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 N WOODFORD ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-2836
Mailing Address - Country:US
Mailing Address - Phone:217-877-1742
Mailing Address - Fax:217-877-2222
Practice Address - Street 1:3250 N WOODFORD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-2836
Practice Address - Country:US
Practice Address - Phone:217-877-1742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027977122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist