Provider Demographics
NPI:1790444248
Name:BOOTZ, SHIRLEY (LDH)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:BOOTZ
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:
Other - Last Name:KEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 DEAN JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-3415
Mailing Address - Country:US
Mailing Address - Phone:574-289-7001
Mailing Address - Fax:
Practice Address - Street 1:220 DEAN JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-3415
Practice Address - Country:US
Practice Address - Phone:574-289-7001
Practice Address - Fax:574-236-7166
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13004216A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist