Provider Demographics
NPI:1417470352
Name:BOSWELL, BRYN
Entity Type:Individual
Prefix:
First Name:BRYN
Middle Name:
Last Name:BOSWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:PHILLIPS
Mailing Address - State:WI
Mailing Address - Zip Code:54555-0010
Mailing Address - Country:US
Mailing Address - Phone:715-339-3021
Mailing Address - Fax:
Practice Address - Street 1:370 3RD AVE S
Practice Address - Street 2:
Practice Address - City:PARK FALLS
Practice Address - State:WI
Practice Address - Zip Code:54552-1228
Practice Address - Country:US
Practice Address - Phone:715-762-2188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001637122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist