Provider Demographics
NPI:1972629715
Name:BOYD, DAVID M (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:BOYD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:M
Other - Last Name:BOYD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:118 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873-1612
Mailing Address - Country:US
Mailing Address - Phone:573-379-3650
Mailing Address - Fax:573-379-5143
Practice Address - Street 1:118 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-1612
Practice Address - Country:US
Practice Address - Phone:573-379-3650
Practice Address - Fax:573-379-5143
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015415332B00000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO403349400Medicaid
MO015415OtherMO. LICENSE NUMBER