MEDICARE: DR. BOONE BREWER 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	122300000X	Dentist	9415	CO

General Provider Information

NPI Number	:	1295931418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BOONE BREWER D.D.S.

Provider Business Mailing Address
First Line	:	1302 BELMONT RD
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-5626
Country	:	US
Telephone Number	:	763-258-6883
Fax Number	:	701-352-2424

Provider Business Practice Location Address
First Line	:	2129 W ELIZABETH ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-4236
Country	:	US
Telephone Number	:	970-493-9116
Fax Number	:

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

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	10/11/2012

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