Healthcare Provider Details

I. General information

NPI: 1205849809
Provider Name (Legal Business Name): DENNIS M BOEKE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 S 3RD
STOCKTON MO
65785-9608
US

IV. Provider business mailing address

1500 N OAKLAND AVE
BOLIVAR MO
65613-3011
US

V. Phone/Fax

Practice location:
  • Phone: 417-276-5131
  • Fax: 417-276-6498
Mailing address:
  • Phone: 417-328-6501
  • Fax: 417-328-6338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO107694
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number107694
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: