=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053644310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSEPH J. BOOTH, DMD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2009
-----------------------------------------------------
Last Update Date | 09/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10009 NORTH LAMAR BLVD SUITE C
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78753-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-491-7800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10009 NORTH LAMAR BLVD SUITE C
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78753-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-491-7800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSEPH BOOTH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 512-432-5147
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 24222
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------