MEDICARE: BOSS DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	047068	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487660114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOSS DENTAL

Provider Business Mailing Address
First Line	:	612 60TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-4101
Country	:	US
Telephone Number	:	718-567-8283
Fax Number	:

Provider Business Practice Location Address
First Line	:	612 60TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-4101
Country	:	US
Telephone Number	:	718-567-8283
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	ANGELA LO
Credential	:
Telephone Number	:	718-567-8283

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	03/27/2013

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Directions to “BOSS DENTAL ” Practice Location

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