Provider Demographics
NPI:1154491496
Name:BOSACKER, SCOTT MARLIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MARLIN
Last Name:BOSACKER
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 1:206 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:IA
Mailing Address - Zip Code:50450-1410
Mailing Address - Country:US
Mailing Address - Phone:641-592-1100
Mailing Address - Fax:641-592-1103
Practice Address - Street 1:206 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:IA
Practice Address - Zip Code:50450-1410
Practice Address - Country:US
Practice Address - Phone:641-592-1100
Practice Address - Fax:641-592-1103
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA66021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00402610Medicaid