=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801013693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID R. BOSCHKEN, D.M.D. INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2007
-----------------------------------------------------
Last Update Date | 01/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 826 ALTOS OAKS DR STE 3
-----------------------------------------------------
City | LOS ALTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94024-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-948-3994
-----------------------------------------------------
Fax | 650-948-3961
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 826 ALTOS OAKS DR STE 3
-----------------------------------------------------
City | LOS ALTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94024-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-948-3994
-----------------------------------------------------
Fax | 650-948-3961
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL COORDINATOR
-----------------------------------------------------
Name | DIANA HARRINGTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 650-948-3994
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 48088
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------