Provider Demographics
NPI:1518367598
Name:BRIAN D BOSTON, DMD, S.C
Entity Type:Organization
Organization Name:BRIAN D BOSTON, DMD, S.C
Other - Org Name:ASPEN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-454-6000
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:866-273-8204
Mailing Address - Fax:866-803-4943
Practice Address - Street 1:2860 S GREEN BAY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4962
Practice Address - Country:US
Practice Address - Phone:262-886-9700
Practice Address - Fax:262-554-1629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty