Healthcare Provider Details

I. General information

NPI: 1285786616
Provider Name (Legal Business Name): BOSWORTH, INC A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7675 DAGGET ST #160
SAN DIEGO CA
92111-2200
US

IV. Provider business mailing address

7675 DAGGET ST #160
SAN DIEGO CA
92111-2200
US

V. Phone/Fax

Practice location:
  • Phone: 858-292-4566
  • Fax: 858-292-5217
Mailing address:
  • Phone: 858-292-4566
  • Fax: 858-292-5217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number55147
License Number StateCA

VIII. Authorized Official

Name: DR. ROBERT L BOSWORTH
Title or Position: OWNER/DENTIST
Credential: DDS,MS
Phone: 858-292-4566