Provider Demographics
NPI:1144254632
Name:BOOTH, FREDERICK ALLEN (DDS,MSD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:ALLEN
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DDS,MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5512
Mailing Address - Country:US
Mailing Address - Phone:910-484-8190
Mailing Address - Fax:910-484-0502
Practice Address - Street 1:222 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5512
Practice Address - Country:US
Practice Address - Phone:910-484-8190
Practice Address - Fax:910-484-0502
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36501223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics