Provider Demographics
NPI:1912574484
Name:BOOTWAY DENTAL LLC
Entity Type:Organization
Organization Name:BOOTWAY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:TUINEI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-750-6897
Mailing Address - Street 1:313 W BOOT RD
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-1109
Mailing Address - Country:US
Mailing Address - Phone:610-701-0102
Mailing Address - Fax:
Practice Address - Street 1:313 W BOOT RD
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-1109
Practice Address - Country:US
Practice Address - Phone:610-701-0102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty