Provider Demographics
NPI:1285951004
Name:BUSAN, BOGDAN ROBERT (DDS)
Entity type:Individual
Prefix:
First Name:BOGDAN
Middle Name:ROBERT
Last Name:BUSAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:
Other - Last Name:BUSAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:4035 MORSAY DR STE 1
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4875
Mailing Address - Country:US
Mailing Address - Phone:815-398-1376
Mailing Address - Fax:
Practice Address - Street 1:4035 MORSAY DR STE 1
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4875
Practice Address - Country:US
Practice Address - Phone:815-398-1376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210024541223P0300X
IL019028190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0300XDental ProvidersDentistPeriodontics