Provider Demographics
NPI:1386014140
Name:BOSWORTH, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 TWO MILE RD
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEGANY
Mailing Address - State:PA
Mailing Address - Zip Code:16743-5018
Mailing Address - Country:US
Mailing Address - Phone:814-642-2732
Mailing Address - Fax:
Practice Address - Street 1:686 TWO MILE RD
Practice Address - Street 2:
Practice Address - City:PORT ALLEGANY
Practice Address - State:PA
Practice Address - Zip Code:16743-5018
Practice Address - Country:US
Practice Address - Phone:814-642-2732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPHDH000015125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist