Provider Demographics
NPI:1194953265
Name:BOSACK, REBECCA (DDS)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BOSACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16045 108TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5345
Mailing Address - Country:US
Mailing Address - Phone:708-403-0005
Mailing Address - Fax:
Practice Address - Street 1:16045 108TH AVE STE A
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5345
Practice Address - Country:US
Practice Address - Phone:708-403-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0279531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice