Provider Demographics
NPI:1295698546
Name:KOSMAN, JAKE (DMD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:KOSMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4791 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44054-1436
Mailing Address - Country:US
Mailing Address - Phone:440-864-7924
Mailing Address - Fax:
Practice Address - Street 1:401 N LEAVITT RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1128
Practice Address - Country:US
Practice Address - Phone:440-988-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-04
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0281961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty