Provider Demographics
NPI:1780373936
Name:LISA M. BOSCH, DMD, LLC
Entity type:Organization
Organization Name:LISA M. BOSCH, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BOSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:660-397-2213
Mailing Address - Street 1:107 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MO
Mailing Address - Zip Code:63537-1426
Mailing Address - Country:US
Mailing Address - Phone:660-397-2213
Mailing Address - Fax:
Practice Address - Street 1:107 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MO
Practice Address - Zip Code:63537-1426
Practice Address - Country:US
Practice Address - Phone:660-397-2213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental