Provider Demographics
NPI:1174615306
Name:BOSWORTH, KELLY B (DDS 9311)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:B
Last Name:BOSWORTH
Suffix:
Gender:M
Credentials:DDS 9311
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Mailing Address - Street 1:24000 HWY 7
Mailing Address - Street 2:SUITE 120 KELLY BOSWORTH FAMILY DENTISTRY
Mailing Address - City:SHOREWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55331
Mailing Address - Country:US
Mailing Address - Phone:952-474-4123
Mailing Address - Fax:952-401-3482
Practice Address - Street 1:24000 HWY 7
Practice Address - Street 2:SUITE 120 KELLY BOSWORTH FAMILY DENTISTRY
Practice Address - City:SHOREWOOD
Practice Address - State:MN
Practice Address - Zip Code:55331
Practice Address - Country:US
Practice Address - Phone:952-474-4123
Practice Address - Fax:952-401-3482
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9311122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist