MEDICARE: DR. STUART WILLIAM BOEKELOO D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	14693	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14693	OTHER	MI	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1356569602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STUART WILLIAM BOEKELOO D.D.S.

Provider Business Mailing Address
First Line	:	2525 S CLEVELAND AVE
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2609
Country	:	US
Telephone Number	:	269-429-6101
Fax Number	:	269-429-7029

Provider Business Practice Location Address
First Line	:	2525 S CLEVELAND AVE
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2609
Country	:	US
Telephone Number	:	269-429-6101
Fax Number	:	269-429-7029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/08/2007

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