Healthcare Provider Details

I. General information

NPI: 1730172263
Provider Name (Legal Business Name): RICHARD TODD BOONE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 N MONTE VISTA ST
ADA OK
74820-7711
US

IV. Provider business mailing address

803 N MONTE VISTA ST
ADA OK
74820-7711
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-3010
  • Fax: 580-332-1302
Mailing address:
  • Phone: 580-332-3010
  • Fax: 580-332-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4808
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: