Provider Demographics
NPI:1528743119
Name:BOEHNKE, KEVIN THOMAS (DDS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:THOMAS
Last Name:BOEHNKE
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 1:2445 260TH ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:IA
Mailing Address - Zip Code:50482-8513
Mailing Address - Country:US
Mailing Address - Phone:641-529-0253
Mailing Address - Fax:
Practice Address - Street 1:2721 W 120TH AVE STE A200
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-3289
Practice Address - Country:US
Practice Address - Phone:303-460-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00205671122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist