Provider Demographics
NPI:1043509334
Name:BOSBOOM, DORLINE H (DDS)
Entity Type:Individual
Prefix:DR
First Name:DORLINE
Middle Name:H
Last Name:BOSBOOM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 EAST 56TH STREET
Mailing Address - Street 2:SUITE #1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022
Mailing Address - Country:US
Mailing Address - Phone:212-752-8151
Mailing Address - Fax:
Practice Address - Street 1:140 EAST 56TH STREET
Practice Address - Street 2:SUITE #1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:212-752-8151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036667122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist