Provider Demographics
NPI:1669580742
Name:BOSQUE VALLEY FAMILY DENTAL
Entity type:Organization
Organization Name:BOSQUE VALLEY FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:NEW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-932-6404
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:701 AVE C
Mailing Address - City:VALLEY MILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76689
Mailing Address - Country:US
Mailing Address - Phone:254-932-6404
Mailing Address - Fax:254-932-6405
Practice Address - Street 1:701 AVE C
Practice Address - Street 2:
Practice Address - City:VALLEY MILLS
Practice Address - State:TX
Practice Address - Zip Code:76689
Practice Address - Country:US
Practice Address - Phone:254-932-6404
Practice Address - Fax:254-932-6405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11551122300000X
TX22305122300000X
TX18658122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty