Provider Demographics
NPI:1255549234
Name:BOSONAC, BRIAN SCOTT (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:SCOTT
Last Name:BOSONAC
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 1:515 BRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6009
Mailing Address - Country:US
Mailing Address - Phone:732-920-0888
Mailing Address - Fax:732-920-5344
Practice Address - Street 1:515 BRICK BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6009
Practice Address - Country:US
Practice Address - Phone:732-920-0888
Practice Address - Fax:732-920-5344
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI 0213541223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics