Provider Demographics
NPI:1366621195
Name:COSMETIC AND FAMILY DENTISTRY OF THE NORTH SHORE PC
Entity type:Organization
Organization Name:COSMETIC AND FAMILY DENTISTRY OF THE NORTH SHORE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:COUSIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-593-1180
Mailing Address - Street 1:128 BURRILL STREET
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907
Mailing Address - Country:US
Mailing Address - Phone:781-593-1180
Mailing Address - Fax:781-581-1180
Practice Address - Street 1:128 BURRILL STREET
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907
Practice Address - Country:US
Practice Address - Phone:781-593-1180
Practice Address - Fax:781-581-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA143411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty