Basic Information
| Provider Information | |||||||||
| NPI: | 1245970839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSSELMAN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | GWEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 LINDEN ST | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015162467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084046751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 128 MEDWAY RD STE 2&3 | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017572915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813251091 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2022 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN1859382 | MA | Y | Dental Providers | Dentist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.