Provider Demographics
NPI:1407288830
Name:BOSMA, KELLEN (DMD)
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:
Last Name:BOSMA
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 1:125 W COLUMBIAN BLVD S
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-3021
Mailing Address - Country:US
Mailing Address - Phone:217-324-2610
Mailing Address - Fax:
Practice Address - Street 1:125 W COLUMBIAN BLVD S
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-3021
Practice Address - Country:US
Practice Address - Phone:217-324-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.029540122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist