Provider Demographics
NPI:1407062342
Name:BOSS DENTAL P.C.
Entity Type:Organization
Organization Name:BOSS DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-247-7367
Mailing Address - Street 1:1501 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3807
Mailing Address - Country:US
Mailing Address - Phone:646-247-7367
Mailing Address - Fax:
Practice Address - Street 1:3708 MAIN ST # 4F
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6509
Practice Address - Country:US
Practice Address - Phone:646-247-7367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOSS DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-15
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0470681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02618188Medicaid