Provider Demographics
NPI:1063942415
Name:BOSSON, DUSTIN CHARLES JEROME (DC)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:CHARLES JEROME
Last Name:BOSSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 SHADALANE WALK
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3045
Mailing Address - Country:US
Mailing Address - Phone:636-328-6693
Mailing Address - Fax:
Practice Address - Street 1:7827 HIGHWAY N STE 102
Practice Address - Street 2:
Practice Address - City:DARDENNE PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63368-7199
Practice Address - Country:US
Practice Address - Phone:636-486-6933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017015434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor