Provider Demographics
NPI:1487660114
Name:BOSS DENTAL
Entity Type:Organization
Organization Name:BOSS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-567-8283
Mailing Address - Street 1:612 60TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-4101
Mailing Address - Country:US
Mailing Address - Phone:718-567-8283
Mailing Address - Fax:
Practice Address - Street 1:612 60TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-4101
Practice Address - Country:US
Practice Address - Phone:718-567-8283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOSS DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-01
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047068122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02618188Medicaid