Basic Information
Provider Information
NPI: 1659755130
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BOEHME
FirstName: GREGARY
MiddleName: R
NamePrefix: DR.
NameSuffix:  
Credential: DMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 523 E HIDDEN COVE LN
Address2:  
City: LEHI
State: UT
PostalCode: 840433607
CountryCode: US
TelephoneNumber: 2085207575
FaxNumber:  
Practice Location
Address1: 945 W 500 N STE 106
Address2:  
City: AMERICAN FORK
State: UT
PostalCode: 840033773
CountryCode: US
TelephoneNumber: 8017565643
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/15/2015
LastUpdateDate: 01/08/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000XD-4687IDY Dental ProvidersDentist 

No ID Information.


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