Provider Demographics
NPI:1720073554
Name:BOEKER, JOHN C (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:BOEKER
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 1:4486 ETTENMOOR LN SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-8741
Mailing Address - Country:US
Mailing Address - Phone:507-288-0177
Mailing Address - Fax:
Practice Address - Street 1:1751 HWY 52 N
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1692
Practice Address - Country:US
Practice Address - Phone:507-282-9288
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice