Provider Demographics
NPI:1467610709
Name:VAN BOSKIRK, THOM S (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOM
Middle Name:S
Last Name:VAN BOSKIRK
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 1:920 N ST
Mailing Address - Street 2:
Mailing Address - City:GERING
Mailing Address - State:NE
Mailing Address - Zip Code:69341-3335
Mailing Address - Country:US
Mailing Address - Phone:308-436-4144
Mailing Address - Fax:
Practice Address - Street 1:920 N ST
Practice Address - Street 2:
Practice Address - City:GERING
Practice Address - State:NE
Practice Address - Zip Code:69341-3335
Practice Address - Country:US
Practice Address - Phone:308-436-4144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-054093300Medicaid