Provider Demographics
NPI:1225040884
Name:BOSCO, STEPHEN JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOHN
Last Name:BOSCO
Suffix:
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 1:1 LAKE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1396
Mailing Address - Country:US
Mailing Address - Phone:860-223-8107
Mailing Address - Fax:860-223-1086
Practice Address - Street 1:1 LAKE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1396
Practice Address - Country:US
Practice Address - Phone:860-223-8107
Practice Address - Fax:860-223-1086
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0060871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT020006087CT01OtherBS
CT07803OtherCONNECTICARE
CT07803OtherCONNECTICARE