Provider Demographics
NPI:1770628539
Name:BOEKE, BRADLEY (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:BOEKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 LAKEVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75088-4027
Mailing Address - Country:US
Mailing Address - Phone:972-840-2020
Mailing Address - Fax:972-694-0260
Practice Address - Street 1:4624 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4027
Practice Address - Country:US
Practice Address - Phone:972-840-2020
Practice Address - Fax:972-694-0260
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX135261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice