Provider Demographics
NPI:1033235221
Name:BOSWELL, BRAD MASON (DDS)
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:MASON
Last Name:BOSWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 TARTAN LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-2410
Mailing Address - Country:US
Mailing Address - Phone:713-784-2952
Mailing Address - Fax:713-184-3331
Practice Address - Street 1:1800 BERING DR STE 650
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-3170
Practice Address - Country:US
Practice Address - Phone:713-784-2952
Practice Address - Fax:713-784-3331
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX138411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice