Provider Demographics
NPI:1245242866
Name:BOSS, JOHN HERBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HERBERT
Last Name:BOSS
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 1:1 RIVER PLACE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-1091
Mailing Address - Country:US
Mailing Address - Phone:978-458-1114
Mailing Address - Fax:978-458-8910
Practice Address - Street 1:1 RIVER PLACE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1091
Practice Address - Country:US
Practice Address - Phone:978-458-1114
Practice Address - Fax:978-458-8910
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA133621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0250813Medicaid
MAX05355OtherMA BLUE CROSS BLUE SHIELD