Provider Demographics
NPI:1841391018
Name:BOATMAN, JACK HOLLAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:HOLLAND
Last Name:BOATMAN
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 1:122 AVENIDA CABRILLO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4039
Mailing Address - Country:US
Mailing Address - Phone:949-498-4110
Mailing Address - Fax:949-498-8657
Practice Address - Street 1:122 AVENIDA CABRILLO
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4039
Practice Address - Country:US
Practice Address - Phone:949-498-4110
Practice Address - Fax:949-498-8657
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA268101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice