Provider Demographics
NPI:1912406455
Name:BOSNJAK, AIDA FATUSIC (RDH, OMT,BBP)
Entity Type:Individual
Prefix:MRS
First Name:AIDA
Middle Name:FATUSIC
Last Name:BOSNJAK
Suffix:
Gender:F
Credentials:RDH, OMT,BBP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 S WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-2696
Mailing Address - Country:US
Mailing Address - Phone:847-234-4800
Mailing Address - Fax:
Practice Address - Street 1:825 S WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-2696
Practice Address - Country:US
Practice Address - Phone:847-234-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-11
Last Update Date:2018-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.010057124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist