Active NPI
Matthew Gregory Boothe, DDS
- Pediatric Dentistry
- Wasilla, AK
National Provider Identifier
1104239136
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- 109471
- Practice address
- 3470 E Meridian Park Loop
Wasilla, AK 99654-7294 - Phone
- (907) 373-8684
- NPI assigned
- Jun 6, 2014
- Last updated
- Sep 2, 2016
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 30627 | TX | |
| Pediatric Dentistry | 1223P0221X | 109471 | AK | Primary |
Addresses
Primary practice location
3470 E Meridian Park Loop
Wasilla, AK 99654-7294
Mailing address
2924 E Odsather Cir
Wasilla, AK 99654-7294
Phone (210) 710-9296
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 30627 | TX | MD | General Practice Dentistry |
| 109471 | AK | MD | Pediatric Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Pediatric Dentistry of Alaska | Pediatric Dentistry | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1402012800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1472774400000",
"number": "1104239136",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2924 E ODSATHER CIR",
"city": "WASILLA",
"state": "AK",
"postal_code": "996547294",
"telephone_number": "210-710-9296"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3470 E MERIDIAN PARK LOOP",
"city": "WASILLA",
"state": "AK",
"postal_code": "996547294",
"telephone_number": "907-373-8684"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOOTHE",
"first_name": "MATTHEW",
"middle_name": "GREGORY",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2014-06-06",
"last_updated": "2016-09-02",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "TX",
"license": "30627",
"primary": false
},
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "AK",
"license": "109471",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Wasilla, AK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 2, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.