Provider Demographics
NPI:1295931418
Name:BREWER, BOONE (DDS)
Entity type:Individual
Prefix:DR
First Name:BOONE
Middle Name:
Last Name:BREWER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 BELMONT RD
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5626
Mailing Address - Country:US
Mailing Address - Phone:763-258-6883
Mailing Address - Fax:701-352-2424
Practice Address - Street 1:2129 W ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-4236
Practice Address - Country:US
Practice Address - Phone:970-493-9116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9415122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist