Provider Demographics
NPI:1548391204
Name:BOSHART, BRYAN FULTON (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:FULTON
Last Name:BOSHART
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 FM 359 RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-2049
Mailing Address - Country:US
Mailing Address - Phone:281-341-8300
Mailing Address - Fax:832-595-0421
Practice Address - Street 1:1840 FM 359 RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-2049
Practice Address - Country:US
Practice Address - Phone:281-341-8300
Practice Address - Fax:832-595-0421
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX147251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics