Provider Demographics
NPI:1750506754
Name:BOSQUE, JUAN CARLOS SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:BOSQUE
Suffix:SR
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 1:5514 BLOCH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-4012
Mailing Address - Country:US
Mailing Address - Phone:858-999-5968
Mailing Address - Fax:
Practice Address - Street 1:3760 CONVOY ST
Practice Address - Street 2:SUITE 330
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3742
Practice Address - Country:US
Practice Address - Phone:858-999-5968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA427231223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics