MEDICARE: DR. JOHN S BOSTIC 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	1223G0001X	General Practice Dentistry	15729	OH

General Provider Information

NPI Number	:	1700865425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN S BOSTIC D.D.S.

Provider Business Mailing Address
First Line	:	14401 SNOW RD
Second Line	:	SUITE 103
City	:	BROOKPARK
State	:	OH
Zip	:	44142-2583
Country	:	US
Telephone Number	:	216-676-4050
Fax Number	:	216-676-4051

Provider Business Practice Location Address
First Line	:	14401 SNOW RD
Second Line	:	SUITE 103
City	:	BROOKPARK
State	:	OH
Zip	:	44142-2583
Country	:	US
Telephone Number	:	216-676-4050
Fax Number	:	216-676-4051

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

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	07/08/2007

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