Provider Demographics
NPI:1962850784
Name:BOSWORTH, ANDREW JON (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JON
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 1:6140 LAKE LINDEN DR
Mailing Address - Street 2:SUITE #230
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-2954
Mailing Address - Country:US
Mailing Address - Phone:952-474-4123
Mailing Address - Fax:
Practice Address - Street 1:6140 LAKE LINDEN DR
Practice Address - Street 2:SUITE #230
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-2954
Practice Address - Country:US
Practice Address - Phone:952-474-4123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13677122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist