Provider Demographics
NPI:1962715904
Name:MENSAH-BOATENG, DANIEL (DDS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MENSAH-BOATENG
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 1:812 LAWRENCE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1192
Mailing Address - Country:US
Mailing Address - Phone:260-387-5890
Mailing Address - Fax:260-444-3149
Practice Address - Street 1:812 LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1192
Practice Address - Country:US
Practice Address - Phone:260-387-5890
Practice Address - Fax:260-444-3149
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011454A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200988310Medicaid