Provider Demographics
NPI:1093232951
Name:ROBERT C. BOSACK, DDS & ASSOCIATES, LTD
Entity Type:Organization
Organization Name:ROBERT C. BOSACK, DDS & ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOSACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-460-9100
Mailing Address - Street 1:16011 108TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8787
Mailing Address - Country:US
Mailing Address - Phone:708-460-9100
Mailing Address - Fax:708-460-7919
Practice Address - Street 1:16011 108TH AVE STE A
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-8787
Practice Address - Country:US
Practice Address - Phone:708-460-9100
Practice Address - Fax:708-460-7919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0011521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1518250125Medicaid
IL1376550558Medicaid