Provider Demographics
NPI:1487729190
Name:BOOTH, JEFFREY PETER (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PETER
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 1:2212 EXECUTIVE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2430
Mailing Address - Country:US
Mailing Address - Phone:757-827-0001
Mailing Address - Fax:757-827-9451
Practice Address - Street 1:2212 EXECUTIVE DR
Practice Address - Street 2:SUITE A
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2430
Practice Address - Country:US
Practice Address - Phone:757-827-0001
Practice Address - Fax:757-827-9451
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010064191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA558705OtherUNITED CONCORDIA PROVIDER