Provider Demographics
NPI:1972255073
Name:BOUTWELL, JOANNA LEA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:LEA
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 FOXWILD CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-7299
Mailing Address - Country:US
Mailing Address - Phone:318-680-8226
Mailing Address - Fax:
Practice Address - Street 1:504 FOXWILD CT
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-7299
Practice Address - Country:US
Practice Address - Phone:318-680-8226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC98851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty