Healthcare Provider Details

I. General information

NPI: 1740920057
Provider Name (Legal Business Name): DANIEL BOATENG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 PEACE ST
PROVIDENCE RI
02907-1510
US

IV. Provider business mailing address

1013 BURNET AVE
UNION NJ
07083-5610
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-4461
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS044467
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: