Provider Demographics
NPI:1962281105
Name:BOUTWELL DENTAL, LLC
Entity type:Organization
Organization Name:BOUTWELL DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR, CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:864-757-2370
Mailing Address - Street 1:309 HIGHWAY 14 STE C
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 HIGHWAY 14 STE C
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-6055
Practice Address - Country:US
Practice Address - Phone:864-757-2370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental