MEDICARE: BARRY FRANK BOOTH DMD LLC

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	261QD0000X	Dental Clinic/Center	5269	AL

General Provider Information

NPI Number	:	1356614135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BARRY FRANK BOOTH DMD LLC

Provider Business Mailing Address
First Line	:	PO BOX 7700
Second Line	:
City	:	SPANISH FORT
State	:	AL
Zip	:	36577-7700
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6475 SPANISH FORT BLVD
Second Line	:	SUITE H
City	:	SPANISH FORT
State	:	AL
Zip	:	36527-9406
Country	:	US
Telephone Number	:	251-654-1563
Fax Number	:	251-625-0211

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. BARRY FRANK BOOTH
Credential	:	DMD
Telephone Number	:	251-654-1563

Provider Enumeration Date	:	02/09/2012
Last Update Date	:	02/09/2012

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