Provider Demographics
NPI:1730865122
Name:BOESE, MANDY KAY-MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:MANDY
Middle Name:KAY-MARIE
Last Name:BOESE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-6224
Mailing Address - Country:US
Mailing Address - Phone:715-513-0240
Mailing Address - Fax:
Practice Address - Street 1:1507 TOWER AVE STE 410
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2562
Practice Address - Country:US
Practice Address - Phone:715-392-6213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001206-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice