MEDICARE: DR. JO-ELLEN BOSSERT DMD

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	0478191	NY

General Provider Information

NPI Number	:	1922145416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JO-ELLEN BOSSERT DMD

Provider Business Mailing Address
First Line	:	4305 E GENESEE ST
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13214-2121
Country	:	US
Telephone Number	:	315-445-5500
Fax Number	:	315-445-1282

Provider Business Practice Location Address
First Line	:	4305 E GENESEE ST
Second Line	:
City	:	DEWITT
State	:	NY
Zip	:	13214-2121
Country	:	US
Telephone Number	:	315-445-5500
Fax Number	:	315-445-1282

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

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	07/08/2007

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