Healthcare Provider Details

I. General information

NPI: 1770584849
Provider Name (Legal Business Name): DR. GERARD BOQUEL
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 RUSSELL AVE SUITE 300
GAITHERSBURG MD
20879-3282
US

IV. Provider business mailing address

903 RUSSELL AVE SUITE 300
GAITHERSBURG MD
20879-3282
US

V. Phone/Fax

Practice location:
  • Phone: 301-869-8884
  • Fax: 301-869-8870
Mailing address:
  • Phone: 301-869-8884
  • Fax: 301-869-8870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number09746
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: