Provider Demographics
NPI:1063403624
Name:COHEN, MITCHELL A (DDS)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:A
Last Name:COHEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 AMHERST ST
Mailing Address - Street 2:PO BOX 232
Mailing Address - City:LAKE GEORGE
Mailing Address - State:NY
Mailing Address - Zip Code:12845-1219
Mailing Address - Country:US
Mailing Address - Phone:518-668-4024
Mailing Address - Fax:518-668-2140
Practice Address - Street 1:48 AMHERST ST
Practice Address - Street 2:
Practice Address - City:LAKE GEORGE
Practice Address - State:NY
Practice Address - Zip Code:12845-1219
Practice Address - Country:US
Practice Address - Phone:518-668-4024
Practice Address - Fax:518-668-2140
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040361-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice