Provider Demographics
NPI:1720372840
Name:BOATEY, MAXWELL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:A
Last Name:BOATEY
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 1:415 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-5839
Mailing Address - Country:US
Mailing Address - Phone:203-634-1515
Mailing Address - Fax:203-634-7519
Practice Address - Street 1:415 BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-5839
Practice Address - Country:US
Practice Address - Phone:203-634-1515
Practice Address - Fax:203-634-7519
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0110721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice