Provider Demographics
NPI:1215098819
Name:BOSWORTH, BRUCE LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LYNN
Last Name:BOSWORTH
Suffix:
Gender:M
Credentials:DDS
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 345
Mailing Address - Street 2:
Mailing Address - City:ONLEY
Mailing Address - State:VA
Mailing Address - Zip Code:23418-0345
Mailing Address - Country:US
Mailing Address - Phone:757-787-8811
Mailing Address - Fax:757-787-8812
Practice Address - Street 1:25529 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:ONLEY
Practice Address - State:VA
Practice Address - Zip Code:23418-0345
Practice Address - Country:US
Practice Address - Phone:757-787-8811
Practice Address - Fax:757-787-8812
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010087961223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics