Provider Demographics
NPI:1013054311
Name:BOSTER, JOSEPH MCKINLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MCKINLEY
Last Name:BOSTER
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 1:2205 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-2832
Mailing Address - Country:US
Mailing Address - Phone:606-248-3674
Mailing Address - Fax:606-248-7277
Practice Address - Street 1:2205 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2832
Practice Address - Country:US
Practice Address - Phone:606-248-3674
Practice Address - Fax:606-248-7277
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60051448Medicaid
KY5144OtherSTATE BOARD OF DENTISTRY