Healthcare Provider Details

I. General information

NPI: 1538729363
Provider Name (Legal Business Name): LISA MICHELLE BOSCH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55682 STATE HIGHWAY 6 STE D
EDINA MO
63537-4268
US

IV. Provider business mailing address

55682 STATE HIGHWAY 6 STE D
EDINA MO
63537-4268
US

V. Phone/Fax

Practice location:
  • Phone: 660-397-2213
  • Fax: 660-397-3929
Mailing address:
  • Phone: 660-397-2213
  • Fax: 660-397-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2019019283
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: