MEDICARE: GINA C. BOSTICK D.D.S.

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	42594	OK
2	1223G0001X	General Practice Dentistry	42594	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19915	OTHER	OK	BNDD
2	42594	OTHER	OK	DENTAL LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689658700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA C. BOSTICK D.D.S.

Provider Business Mailing Address
First Line	:	1901 SPRINGLAKE DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-5201
Country	:	US
Telephone Number	:	405-419-9800
Fax Number	:	405-769-9685

Provider Business Practice Location Address
First Line	:	1901 SPRINGLAKE DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-5201
Country	:	US
Telephone Number	:	405-521-8486
Fax Number	:	405-521-8496

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	03/07/2023

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