Provider Demographics
NPI:1528076932
Name:BOOTH, DONALD FREDERICK (DMD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:FREDERICK
Last Name:BOOTH
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 1:100 E NEWTON ST
Mailing Address - Street 2:G407
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2308
Mailing Address - Country:US
Mailing Address - Phone:617-638-4350
Mailing Address - Fax:617-638-4365
Practice Address - Street 1:100 E NEWTON ST
Practice Address - Street 2:G407
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-638-4350
Practice Address - Fax:617-638-4352
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA95171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0203505Medicaid
16396UHOtherHPHC
T58505Medicare UPIN
X02972Medicare ID - Type Unspecified