Healthcare Provider Details

I. General information

NPI: 1396385175
Provider Name (Legal Business Name): BOSCH DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 SNELLING AVE N
ROSEVILLE MN
55113-1876
US

IV. Provider business mailing address

2680 SNELLING AVE N STE 280
ROSEVILLE MN
55113-1877
US

V. Phone/Fax

Practice location:
  • Phone: 651-488-5557
  • Fax:
Mailing address:
  • Phone: 651-488-5557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RILEY BOSCH
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 651-336-7789