Provider Demographics
NPI:1770639171
Name:BOOTH, MICHAEL S (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:BOOTH
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 1:1305 PHYSICIANS DR.
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7352
Mailing Address - Country:US
Mailing Address - Phone:910-762-2618
Mailing Address - Fax:910-763-5173
Practice Address - Street 1:1305 PHYSICIANS DR.
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7352
Practice Address - Country:US
Practice Address - Phone:910-762-2618
Practice Address - Fax:910-763-5173
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC71121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery