Provider Demographics
NPI:1841413630
Name:BOSTON, DANIEL AGEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:AGEE
Last Name:BOSTON
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 1:1320 N 600 E
Mailing Address - Street 2:#1
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2431
Mailing Address - Country:US
Mailing Address - Phone:453-752-3343
Mailing Address - Fax:435-787-1825
Practice Address - Street 1:1320 N 600 E
Practice Address - Street 2:SUITE #1
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2431
Practice Address - Country:US
Practice Address - Phone:453-752-3343
Practice Address - Fax:435-787-1825
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT137627-9922122300000X
UT137627-8903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist