Provider Demographics
NPI:1841746450
Name:BOSCOBEL FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:BOSCOBEL FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:K
Authorized Official - Last Name:SALMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-647-3222
Mailing Address - Street 1:105 E BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1610
Mailing Address - Country:US
Mailing Address - Phone:608-375-4549
Mailing Address - Fax:608-375-4665
Practice Address - Street 1:105 E. BLUFF STREET
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805
Practice Address - Country:US
Practice Address - Phone:608-375-4549
Practice Address - Fax:608-375-4665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10013941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty