MEDICARE: DR. MARK BOECHE D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3112	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063678407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK BOECHE D.D.S.

Provider Business Mailing Address
First Line	:	1915 E MILWAUKEE ST
Second Line	:
City	:	JANESVILLE
State	:	WI
Zip	:	53545-2647
Country	:	US
Telephone Number	:	608-754-5768
Fax Number	:	608-754-7195

Provider Business Practice Location Address
First Line	:	1915 E MILWAUKEE ST
Second Line	:
City	:	JANESVILLE
State	:	WI
Zip	:	53545-2647
Country	:	US
Telephone Number	:	608-754-5768
Fax Number	:	608-754-7195

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2008
Last Update Date	:	08/05/2008

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