Provider Demographics
NPI:1821207283
Name:BOSEMAN, J. JERALD (DDS)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:JERALD
Last Name:BOSEMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:JERALD
Other - Last Name:BOSEMAN
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:4190 HIGHLAND DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2600
Mailing Address - Country:US
Mailing Address - Phone:801-278-0840
Mailing Address - Fax:801-278-8414
Practice Address - Street 1:4190 S HIGHLAND DR
Practice Address - Street 2:SUITE 106
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2600
Practice Address - Country:US
Practice Address - Phone:801-278-0840
Practice Address - Fax:801-278-8414
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT140450-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist