MEDICARE: MR. BILLY FREDERICK BOOTY JR. DDS

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	122300000X	Dentist	5311	LA

General Provider Information

NPI Number	:	1386703544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BILLY FREDERICK BOOTY JR. DDS

Provider Business Mailing Address
First Line	:	1962 O' NEAL LANE
Second Line	:	#A & B
City	:	BATON ROUGE
State	:	LA
Zip	:	70816
Country	:	US
Telephone Number	:	225-753-5303
Fax Number	:	225-753-3921

Provider Business Practice Location Address
First Line	:	1962 O' NEAL LANE
Second Line	:	#A & B
City	:	BATON ROUGE
State	:	LA
Zip	:	70816
Country	:	US
Telephone Number	:	225-753-5303
Fax Number	:	225-753-3921

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

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	07/29/2015

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