Provider Demographics
NPI:1770629065
Name:BOOTH, BARRY E (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:E
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12635 W 143RD ST
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8381
Mailing Address - Country:US
Mailing Address - Phone:708-301-0005
Mailing Address - Fax:708-301-0063
Practice Address - Street 1:12635 W 143RD ST
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-8381
Practice Address - Country:US
Practice Address - Phone:708-301-0005
Practice Address - Fax:708-301-0063
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics