Provider Demographics
NPI:1730299694
Name:BOOTH, GREGORY ALAN (D D S)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:BOOTH
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 CAPITOL ST
Mailing Address - Street 2:101S.
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2847
Mailing Address - Country:US
Mailing Address - Phone:801-621-5910
Mailing Address - Fax:801-392-7154
Practice Address - Street 1:1245 CAPITOL ST
Practice Address - Street 2:101S.
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-2847
Practice Address - Country:US
Practice Address - Phone:801-621-5910
Practice Address - Fax:801-392-7154
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1362461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice