Healthcare Provider Details

I. General information

NPI: 1033284948
Provider Name (Legal Business Name): BARRY LEE BOOTH D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 SPANISH FORT BLVD
SPANISH FORT AL
36527
US

IV. Provider business mailing address

PO BOX 7406
SPANISH FORT AL
36577-7406
US

V. Phone/Fax

Practice location:
  • Phone: 251-626-3211
  • Fax: 251-625-0211
Mailing address:
  • Phone: 251-626-3211
  • Fax: 251-625-0211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2701
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: