Healthcare Provider Details

I. General information

NPI: 1598009268
Provider Name (Legal Business Name): JON MICHAEL BOATMAN RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MIKE BOATMAN RDH

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 TUCKER RD
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

6501 SAN ANTONIO DR NE UNIT 602
ALBUQUERQUE NM
87109-4139
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4513
  • Fax:
Mailing address:
  • Phone: 505-459-5871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH3760
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: