Healthcare Provider Details

I. General information

NPI: 1134224116
Provider Name (Legal Business Name): JERRY B BOOTH D.D.S, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

683 ROBINSON RD
JACKSON MI
49203-1155
US

IV. Provider business mailing address

505 N JACKSON ST
JACKSON MI
49201-1266
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-0417
  • Fax: 517-787-5536
Mailing address:
  • Phone: 517-748-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberJB008016
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: