Basic Information
| Provider Information | |||||||||
| NPI: | 1104030477 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOECKH | ||||||||
| FirstName: | MARTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3845 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301061109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707392100 | ||||||||
| FaxNumber: | 8508372042 | ||||||||
| Practice Location | |||||||||
| Address1: | 3845 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301061109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707392100 | ||||||||
| FaxNumber: | 8508372042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 7521 | GA | Y | Dental Providers | Dentist | General Practice |
No ID Information.