Healthcare Provider Details

I. General information

NPI: 1598741779
Provider Name (Legal Business Name): MARK BOONE D.M.D., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USNDC FAR EAST PSC 475 BOX 1857
FPO AP
96350
JP

IV. Provider business mailing address

USNDC FAR EAST PSC 475 BOX 1857
FPO AP
96350
JP

V. Phone/Fax

Practice location:
  • Phone: 01181468168808
  • Fax:
Mailing address:
  • Phone: 01181468168808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7490
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: