Provider Demographics
NPI:1215483094
Name:BOATWRIGHT CRUMP, SHANTRYCE MONIQUE (RDH)
Entity type:Individual
Prefix:MRS
First Name:SHANTRYCE
Middle Name:MONIQUE
Last Name:BOATWRIGHT CRUMP
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:SHANTRYCE
Other - Middle Name:MONIQUE
Other - Last Name:BOATWRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:2617 RIELLY ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310
Mailing Address - Country:US
Mailing Address - Phone:910-643-2219
Mailing Address - Fax:
Practice Address - Street 1:2617 RIELLY ROAD
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310
Practice Address - Country:US
Practice Address - Phone:910-643-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8117124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist