Provider Demographics
NPI:1659439859
Name:BOATMAN, RICHARD R (DMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:BOATMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 EDWARDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-1336
Mailing Address - Country:US
Mailing Address - Phone:618-667-8020
Mailing Address - Fax:618-667-8078
Practice Address - Street 1:606 EDWARDSVILLE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-1336
Practice Address - Country:US
Practice Address - Phone:618-667-8020
Practice Address - Fax:618-667-8078
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist