Provider Demographics
NPI:1548839152
Name:BOOTA, ISAAC JOSEPH (DMD)
Entity type:Individual
Prefix:DR
First Name:ISAAC
Middle Name:JOSEPH
Last Name:BOOTA
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 1:6606 MEZZO LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-1995
Mailing Address - Country:US
Mailing Address - Phone:252-227-8777
Mailing Address - Fax:
Practice Address - Street 1:2385 TIMBER DR
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-2586
Practice Address - Country:US
Practice Address - Phone:919-772-1434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC122831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice