Healthcare Provider Details

I. General information

NPI: 1104230804
Provider Name (Legal Business Name): KYLE BOSK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 DELTA AVE
GLADSTONE MI
49837-1438
US

IV. Provider business mailing address

1103 DELTA AVE
GLADSTONE MI
49837-1438
US

V. Phone/Fax

Practice location:
  • Phone: 906-428-1616
  • Fax: 906-428-2177
Mailing address:
  • Phone: 906-428-1616
  • Fax: 906-428-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901021293
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: