Provider Demographics
NPI:1134224116
Name:BOOTH, JERRY B (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:B
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1266
Mailing Address - Country:US
Mailing Address - Phone:517-748-5500
Mailing Address - Fax:
Practice Address - Street 1:683 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-1155
Practice Address - Country:US
Practice Address - Phone:517-787-0417
Practice Address - Fax:517-787-5536
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJB0080161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC87608001Medicare ID - Type Unspecified
MIT82800Medicare UPIN