Provider Demographics
NPI:1982720520
Name:BOALES, OWEN J (DMD)
Entity Type:Individual
Prefix:DR
First Name:OWEN
Middle Name:J
Last Name:BOALES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:FL
Mailing Address - Zip Code:32052-5847
Mailing Address - Country:US
Mailing Address - Phone:386-792-1197
Mailing Address - Fax:386-792-1048
Practice Address - Street 1:1133 4TH ST NW
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-5847
Practice Address - Country:US
Practice Address - Phone:386-792-1197
Practice Address - Fax:386-792-1048
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD87911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice