Provider Demographics
NPI:1538729363
Name:BOSCH, LISA MICHELLE (DMD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MICHELLE
Last Name:BOSCH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55682 STATE HIGHWAY 6 STE D
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MO
Mailing Address - Zip Code:63537-4268
Mailing Address - Country:US
Mailing Address - Phone:660-397-2213
Mailing Address - Fax:660-397-3929
Practice Address - Street 1:55682 STATE HIGHWAY 6 STE D
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MO
Practice Address - Zip Code:63537-4268
Practice Address - Country:US
Practice Address - Phone:660-397-2213
Practice Address - Fax:660-397-3929
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019019283122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019019283OtherDENTIST