Provider Demographics
NPI:1356569602
Name:BOEKELOO, STUART WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:WILLIAM
Last Name:BOEKELOO
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 1:2525 S CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2609
Mailing Address - Country:US
Mailing Address - Phone:269-429-6101
Mailing Address - Fax:269-429-7029
Practice Address - Street 1:2525 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2609
Practice Address - Country:US
Practice Address - Phone:269-429-6101
Practice Address - Fax:269-429-7029
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI146931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI14693OtherSTATE LICENSE NUMBER