Provider Demographics
NPI:1164441838
Name:BOSAK, JOHN E JR (DMD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:E
Last Name:BOSAK
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10727 WHITE OAK AVE STE 213
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-4656
Mailing Address - Country:US
Mailing Address - Phone:818-368-5676
Mailing Address - Fax:818-368-6862
Practice Address - Street 1:10727 WHITE OAK AVE STE 213
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-4656
Practice Address - Country:US
Practice Address - Phone:818-368-5676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38260122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist