# KELLY BOSWORTH, DDS, INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1518125160
- **Authorized official:** KERIANN GERMAN (FINANCIAL COORDINATOR)
- **Authorized official phone:** (952) 474-4123

## Contact information

- **Practice address:** 6140 LAKE LINDEN DR, SUITE 230, EXCELSIOR, MN 55331-2954
- **Practice address phone:** (952) 474-4123
- **Practice address fax:** (952) 401-3482
- **Mailing address:** 6140 LAKE LINDEN DR, SUITE 230, EXCELSIOR, MN 55331-2954
- **Mailing address phone:** (952) 474-4123
- **Mailing address fax:** (952) 401-3482

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 9311 | MN | Yes |

## Other

- **Enumeration date:** 05/30/2008
- **Last updated:** 05/30/2008