Provider Demographics
NPI:1578295242
Name:BOOTH, MICHELLE AGNES (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:AGNES
Last Name:BOOTH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 S CRESTLINE ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-6825
Mailing Address - Country:US
Mailing Address - Phone:435-265-2727
Mailing Address - Fax:
Practice Address - Street 1:6817 N CEDAR RD STE 202
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-4277
Practice Address - Country:US
Practice Address - Phone:509-283-7914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS622281223G0001X
WADE616216711223G0001X
FLDN273621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice