Provider Demographics
NPI:1083883722
Name:JERRY L. BOSHELL, D.M.D., P.C.
Entity Type:Organization
Organization Name:JERRY L. BOSHELL, D.M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOSHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PHD
Authorized Official - Phone:205-221-2330
Mailing Address - Street 1:1606 6TH AVE S
Mailing Address - Street 2:P.O. BOX 3125
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-4640
Mailing Address - Country:US
Mailing Address - Phone:205-221-2330
Mailing Address - Fax:205-221-3961
Practice Address - Street 1:1606 6TH AVE S
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-4640
Practice Address - Country:US
Practice Address - Phone:205-221-2330
Practice Address - Fax:205-221-3961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3149261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental