Provider Demographics
NPI:1275548034
Name:BOSS DENTAL
Entity Type:Organization
Organization Name:BOSS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-274-8658
Mailing Address - Street 1:52 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-6868
Mailing Address - Country:US
Mailing Address - Phone:212-274-8658
Mailing Address - Fax:212-274-8571
Practice Address - Street 1:52 E BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-6868
Practice Address - Country:US
Practice Address - Phone:212-274-8658
Practice Address - Fax:212-274-8571
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOSS DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-30
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047068122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty