Provider Demographics
NPI:1316053556
Name:WICKFORD DENTAL ASSOC INC
Entity type:Organization
Organization Name:WICKFORD DENTAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:N
Authorized Official - Last Name:BOSCRA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-295-8806
Mailing Address - Street 1:181 WEST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:N KINGSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02852
Mailing Address - Country:US
Mailing Address - Phone:401-295-8806
Mailing Address - Fax:401-295-8828
Practice Address - Street 1:181 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:N KINGSTON
Practice Address - State:RI
Practice Address - Zip Code:02852
Practice Address - Country:US
Practice Address - Phone:401-295-8806
Practice Address - Fax:401-295-8828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN02574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty