=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982247938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERNARD D BOS DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2019
-----------------------------------------------------
Last Update Date | 10/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19230 MCLOUGHLIN BLVD
-----------------------------------------------------
City | GLADSTONE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97027-2625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-656-1208
-----------------------------------------------------
Fax | 503-722-1822
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19230 MCLOUGHLIN BLVD
-----------------------------------------------------
City | GLADSTONE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97027-2625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-656-1208
-----------------------------------------------------
Fax | 503-722-1822
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. BERNARD DEAN BOS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 503-784-2471
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------