Provider Demographics
NPI:1376550558
Name:BOSACK, ROBERT C (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:BOSACK
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 1:16011 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8786
Mailing Address - Country:US
Mailing Address - Phone:708-460-9100
Mailing Address - Fax:708-460-7919
Practice Address - Street 1:16011 108TH AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-8786
Practice Address - Country:US
Practice Address - Phone:708-460-9100
Practice Address - Fax:708-460-7919
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL716710Medicare PIN