Healthcare Provider Details

I. General information

NPI: 1063539849
Provider Name (Legal Business Name): PAUL RICHARD BOECLER D.M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

958 JOE FRANK HARRIS PKWY SE BLDG A SUITE 104
CARTERSVILLE GA
30120-2151
US

IV. Provider business mailing address

958 JOE FRANK HARRIS PKWY SE BLDG A SUITE 104
CARTERSVILLE GA
30120-2151
US

V. Phone/Fax

Practice location:
  • Phone: 770-386-2442
  • Fax: 770-386-2442
Mailing address:
  • Phone: 770-386-2442
  • Fax: 770-386-2442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN009792
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: