Provider Demographics
NPI:1194162446
Name:JOHN E. BOSAK, JR., DMD, A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:JOHN E. BOSAK, JR., DMD, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BOSAK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-368-5676
Mailing Address - Street 1:10727 WHITE OAK AVE
Mailing Address - Street 2:SUITE 213
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-4631
Mailing Address - Country:US
Mailing Address - Phone:818-368-5676
Mailing Address - Fax:
Practice Address - Street 1:10727 WHITE OAK AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-4631
Practice Address - Country:US
Practice Address - Phone:818-368-5676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty