Healthcare Provider Details

I. General information

NPI: 1063490118
Provider Name (Legal Business Name): MICHAEL JOHN BOOTH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2006
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32560 UTICA RD
FRASER MI
48026-2215
US

IV. Provider business mailing address

32560 UTICA RD
FRASER MI
48026-2215
US

V. Phone/Fax

Practice location:
  • Phone: 586-293-8530
  • Fax: 586-293-6539
Mailing address:
  • Phone: 586-293-8530
  • Fax: 586-293-6539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13125
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: