Provider Demographics
NPI:1649914938
Name:BOONE, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BOONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W KINGS RD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-8219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7221 NW 23RD ST UNIT C-D
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-5131
Practice Address - Country:US
Practice Address - Phone:405-367-8147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-23
Last Update Date:2025-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK75601223X0400X
NVLL-573-22122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics