Provider Demographics
NPI:1043540552
Name:BOSCIA, MATTHEW JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JAMES
Last Name:BOSCIA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 LAKESIDE DR STE A
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1378
Mailing Address - Country:US
Mailing Address - Phone:636-625-1225
Mailing Address - Fax:636-625-1228
Practice Address - Street 1:15 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1378
Practice Address - Country:US
Practice Address - Phone:636-625-1225
Practice Address - Fax:636-625-1228
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003013106332B00000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies