Provider Demographics
NPI:1780815928
Name:BOSE, RAISON SUJAI (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAISON
Middle Name:SUJAI
Last Name:BOSE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2600 N MAYFAIR RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1309
Mailing Address - Country:US
Mailing Address - Phone:414-258-1500
Mailing Address - Fax:414-258-9353
Practice Address - Street 1:2600 N MAYFAIR RD
Practice Address - Street 2:SUITE 240
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1309
Practice Address - Country:US
Practice Address - Phone:414-258-1500
Practice Address - Fax:414-258-9353
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6750-0151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXUTSA 887XOtherTEXAS STATE BOARD OF DENTAL EXAMINERS