Provider Demographics
NPI:1609880962
Name:BOAG, DAVID R (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:BOAG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:403 HIGHWAY 74 N
Mailing Address - Street 2:STE. A
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3963
Mailing Address - Country:US
Mailing Address - Phone:770-631-3380
Mailing Address - Fax:770-631-3383
Practice Address - Street 1:403 HIGHWAY 74 N
Practice Address - Street 2:STE. A
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3963
Practice Address - Country:US
Practice Address - Phone:770-631-3380
Practice Address - Fax:770-631-3383
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0118301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice