Healthcare Provider Details

I. General information

NPI: 1376550558
Provider Name (Legal Business Name): ROBERT C. BOSACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16011 108TH AVE
ORLAND PARK IL
60467-8786
US

IV. Provider business mailing address

16011 108TH AVE
ORLAND PARK IL
60467-8786
US

V. Phone/Fax

Practice location:
  • Phone: 708-460-9100
  • Fax: 708-460-7919
Mailing address:
  • Phone: 708-460-9100
  • Fax: 708-460-7919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: