Provider Demographics
NPI:1992871297
Name:BOOTH, JOHN DOUGLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DOUGLAS
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 1:2410 L AND N DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801
Mailing Address - Country:US
Mailing Address - Phone:256-533-4770
Mailing Address - Fax:256-489-4770
Practice Address - Street 1:2410 L AND N DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-533-4770
Practice Address - Fax:256-489-4770
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
694058OtherUNITED CONCORDIA
AL90431OtherBLUE CROSS