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General NPI Number Information
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NPI Number | 1780830687
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Entity Type | Individual
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Provider Name | BRANDON BOEKAMP FOWLER D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/11/2008
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Last Update Date | 12/04/2023
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Provider Practice Location Address
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Address Line | 2015 S EAGLE RD
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City | MERIDIAN
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State | ID
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Zip | 83642-6707
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Country | US
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Telephone | 208-887-1053
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Fax |
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Provider Business Mailing Address
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Address Line | 2815 EL RASTRO LN
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City | CARLSBAD
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State | CA
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Zip | 92009-9215
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Country | US
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Telephone | 619-933-6146
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 57470
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 57470
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | D-4813-OR
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License Number State | ID
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