Provider Demographics
NPI:1285032011
Name:BOSEMAN, JODY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:
Last Name:BOSEMAN
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 1:4698 S HIGHLAND DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5265
Mailing Address - Country:US
Mailing Address - Phone:801-278-0840
Mailing Address - Fax:801-278-8414
Practice Address - Street 1:4698 S HIGHLAND DR STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5265
Practice Address - Country:US
Practice Address - Phone:801-278-0840
Practice Address - Fax:801-278-8414
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1423991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice