Provider Demographics
NPI:1104239136
Name:BOOTHE, MATTHEW GREGORY (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:GREGORY
Last Name:BOOTHE
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 1:2924 E ODSATHER CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7294
Mailing Address - Country:US
Mailing Address - Phone:210-710-9296
Mailing Address - Fax:
Practice Address - Street 1:3470 E MERIDIAN PARK LOOP
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7294
Practice Address - Country:US
Practice Address - Phone:907-373-8684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX306271223G0001X
AK1094711223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice