Provider Demographics
NPI:1851670152
Name:BOYLE, CLINT (DMD)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:
Last Name:BOYLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4403
Mailing Address - Country:US
Mailing Address - Phone:309-663-0433
Mailing Address - Fax:
Practice Address - Street 1:107 S PROSPECT RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4403
Practice Address - Country:US
Practice Address - Phone:309-663-0433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028642122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist