Provider Demographics
NPI:1063490365
Name:ROBERT A BOSQUE JR DMD PC
Entity Type:Organization
Organization Name:ROBERT A BOSQUE JR DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BOSQUE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-355-0555
Mailing Address - Street 1:723 E 65TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4408
Mailing Address - Country:US
Mailing Address - Phone:912-355-0555
Mailing Address - Fax:912-353-9042
Practice Address - Street 1:723 E 65TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4408
Practice Address - Country:US
Practice Address - Phone:912-355-0555
Practice Address - Fax:912-353-9042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0096191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty