Provider Demographics
NPI:1770108102
Name:BOUTWELL, JOHN FRAZIER (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FRAZIER
Last Name:BOUTWELL
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 1:3369 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4105
Mailing Address - Country:US
Mailing Address - Phone:864-297-6365
Mailing Address - Fax:
Practice Address - Street 1:3369 PELHAM RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4105
Practice Address - Country:US
Practice Address - Phone:864-297-6365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7099122300000X
SC9855122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist