Provider Demographics
NPI:1659755130
Name:BOEHME, GREGARY R (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGARY
Middle Name:R
Last Name:BOEHME
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 1:2152 VILLAGE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4172
Mailing Address - Country:US
Mailing Address - Phone:208-735-5599
Mailing Address - Fax:208-735-5597
Practice Address - Street 1:2152 VILLAGE PARK AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4172
Practice Address - Country:US
Practice Address - Phone:208-735-5599
Practice Address - Fax:208-735-5597
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-15
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4687122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist