Provider Demographics
NPI:1457372948
Name:BOSTICK, EARL SR (DMD)
Entity type:Individual
Prefix:DR
First Name:EARL
Middle Name:
Last Name:BOSTICK
Suffix:SR
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:PO BOX 2260
Mailing Address - Street 2:110 JACOB SMART BLVD.
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-2638
Mailing Address - Country:US
Mailing Address - Phone:843-726-5711
Mailing Address - Fax:
Practice Address - Street 1:110 JACOB SMART BLVD.
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936
Practice Address - Country:US
Practice Address - Phone:843-726-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC002311122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist