Provider Demographics
NPI:1639242993
Name:BOE, ANTHONY WALTER (DDS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:WALTER
Last Name:BOE
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 1:1880 W WAYZATA BLVD
Mailing Address - Street 2:P O BOX 128
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-9491
Mailing Address - Country:US
Mailing Address - Phone:952-475-0989
Mailing Address - Fax:952-475-2053
Practice Address - Street 1:1880 W WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55356-9491
Practice Address - Country:US
Practice Address - Phone:952-475-0989
Practice Address - Fax:952-475-2053
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND84811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN91D71B0OtherBLUE CROSS BLUE SHIELD ID
MND8481OtherMN BOARD OF DENTISTRY #