=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962850784
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW JON BOSWORTH D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2016
-----------------------------------------------------
Last Update Date | 06/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6140 LAKE LINDEN DR SUITE #230
-----------------------------------------------------
City | EXCELSIOR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55331-2954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-474-4123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6140 LAKE LINDEN DR SUITE #230
-----------------------------------------------------
City | EXCELSIOR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55331-2954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-474-4123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D13677
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------