Provider Demographics
NPI:1316119795
Name:COSMET ENTERPRISE LLC
Entity type:Organization
Organization Name:COSMET ENTERPRISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:352-408-1400
Mailing Address - Street 1:10250 SE 167TH PLACE RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-8682
Mailing Address - Country:US
Mailing Address - Phone:352-245-0780
Mailing Address - Fax:352-347-8369
Practice Address - Street 1:10250 SE 167TH PLACE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8682
Practice Address - Country:US
Practice Address - Phone:352-245-0780
Practice Address - Fax:352-347-8369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty