Provider Demographics
NPI:1083644892
Name:KOSSAK, MICHAEL EDWARD (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:KOSSAK
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 1:1234 19TH ST NW
Mailing Address - Street 2:SUITE # 308
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20036-2407
Mailing Address - Country:US
Mailing Address - Phone:202-393-6154
Mailing Address - Fax:202-293-1914
Practice Address - Street 1:1234 19TH ST NW
Practice Address - Street 2:SUITE # 308
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-2407
Practice Address - Country:US
Practice Address - Phone:202-393-6154
Practice Address - Fax:202-293-1914
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC30521223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics