Provider Demographics
NPI:1083789937
Name:BOSWELL, BRYANT RIDGWAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:RIDGWAY
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 1:1513 LAKELAND DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-366-1242
Mailing Address - Fax:601-366-1275
Practice Address - Street 1:1513 LAKELAND DR
Practice Address - Street 2:SUITE 201
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-366-1242
Practice Address - Fax:601-366-1275
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1451 71122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist