Provider Demographics
NPI:1144382961
Name:KOSOBUCKI, ROBERT GEORGE (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GEORGE
Last Name:KOSOBUCKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12011 S 86TH AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1221
Mailing Address - Country:US
Mailing Address - Phone:708-302-6953
Mailing Address - Fax:708-302-6953
Practice Address - Street 1:12011 S 86TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1221
Practice Address - Country:US
Practice Address - Phone:708-302-6953
Practice Address - Fax:708-302-6953
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19014600122300000X
IL0210008611223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist