Provider Demographics
NPI:1063894921
Name:BOOTH, JOEL (DDS)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 N MERIDIAN RD STE 106
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3508
Mailing Address - Country:US
Mailing Address - Phone:406-752-6684
Mailing Address - Fax:
Practice Address - Street 1:690 N MERIDIAN RD STE 106
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-752-6684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9618122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist