Provider Demographics
NPI:1770627358
Name:BOAK, ANDRA MARGARET (DMD)
Entity Type:Individual
Prefix:
First Name:ANDRA
Middle Name:MARGARET
Last Name:BOAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 FIRST ST
Mailing Address - Street 2:18TH FLLOR
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-1200
Mailing Address - Country:US
Mailing Address - Phone:207-490-6900
Mailing Address - Fax:207-490-1188
Practice Address - Street 1:245 FIRST ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02142-1200
Practice Address - Country:US
Practice Address - Phone:207-490-6900
Practice Address - Fax:207-490-1188
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME37951223G0001X
MA214551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432332399OtherMAINE CARE PROVIDER NUMBE