Provider Demographics
NPI:1306902093
Name:BOOTH, JAMES L (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:L
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 1:121 W KAGY BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6000
Mailing Address - Country:US
Mailing Address - Phone:406-586-5888
Mailing Address - Fax:
Practice Address - Street 1:121 W KAGY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6000
Practice Address - Country:US
Practice Address - Phone:406-586-5888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT14741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTT89345Medicare UPIN