MEDICARE: DR. MICHELLE AGNES BOOTH DDS

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	62228	KS
2	1223G0001X	General Practice Dentistry	DE61621671	WA
3	1223G0001X	General Practice Dentistry	DN27362	FL

General Provider Information

NPI Number	:	1578295242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE AGNES BOOTH DDS

Provider Business Mailing Address
First Line	:	6121 S CRESTLINE ST
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99223-6825
Country	:	US
Telephone Number	:	435-265-2727
Fax Number	:

Provider Business Practice Location Address
First Line	:	6817 N CEDAR RD STE 202
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99208-4277
Country	:	US
Telephone Number	:	509-283-7914
Fax Number	:

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

Provider Enumeration Date	:	06/30/2022
Last Update Date	:	04/02/2026

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