Healthcare Provider Details

I. General information

NPI: 1982843785
Provider Name (Legal Business Name): BOSS DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 57TH STREET, 1ST FL
BROOKLYN NY
11220-3645
US

IV. Provider business mailing address

821 57TH STREET, 1ST FL
BROOKLYN NY
11220-3645
US

V. Phone/Fax

Practice location:
  • Phone: 718-686-0313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number047068
License Number StateNY

VIII. Authorized Official

Name: ANGELA LO
Title or Position: MANAGER
Credential:
Phone: 718-886-7222