Provider Demographics
NPI:1184782104
Name:BOSTICK, CHRISTOPHER LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:LEE
Last Name:BOSTICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 DANIEL DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2527
Mailing Address - Country:US
Mailing Address - Phone:859-236-1810
Mailing Address - Fax:859-236-1802
Practice Address - Street 1:122 DANIEL DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2527
Practice Address - Country:US
Practice Address - Phone:859-236-1810
Practice Address - Fax:859-236-1802
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8078122300000X, 1223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1356706006OtherMEDICARE NSC