Provider Demographics
NPI:1518125160
Name:KELLY BOSWORTH, DDS, INC
Entity Type:Organization
Organization Name:KELLY BOSWORTH, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KERIANN
Authorized Official - Middle Name:
Authorized Official - Last Name:GERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-474-4123
Mailing Address - Street 1:6140 LAKE LINDEN DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-2954
Mailing Address - Country:US
Mailing Address - Phone:952-474-4123
Mailing Address - Fax:952-401-3482
Practice Address - Street 1:6140 LAKE LINDEN DR
Practice Address - Street 2:SUITE 230
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-2954
Practice Address - Country:US
Practice Address - Phone:952-474-4123
Practice Address - Fax:952-401-3482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN93111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty