Provider Demographics
NPI:1821562323
Name:BOOTH ORTHODONTICS LLC
Entity Type:Organization
Organization Name:BOOTH ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:708-301-0005
Mailing Address - Street 1:12635 W 143RD ST
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8381
Mailing Address - Country:US
Mailing Address - Phone:708-301-0005
Mailing Address - Fax:
Practice Address - Street 1:12635 W 143RD ST
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-8381
Practice Address - Country:US
Practice Address - Phone:708-301-0005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty