Provider Demographics
NPI:1811452303
Name:BOEHM, AUDRA ALEXANDRA
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:ALEXANDRA
Last Name:BOEHM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8745 PACIFIC AVE NW # 102
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8394
Mailing Address - Country:US
Mailing Address - Phone:602-045-1223
Mailing Address - Fax:
Practice Address - Street 1:8745 PACIFIC AVE NW # 102
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8394
Practice Address - Country:US
Practice Address - Phone:602-045-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE616630021223S0112X
390200000X
WAMD616630111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program