Provider Demographics
NPI:1386086213
Name:KOSTER, KARISSA RAE (DMD)
Entity type:Individual
Prefix:DR
First Name:KARISSA
Middle Name:RAE
Last Name:KOSTER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KARISSA
Other - Middle Name:RAE
Other - Last Name:NICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:159 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1842 BEACON ST
Practice Address - Street 2:SUITE 401
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-1930
Practice Address - Country:US
Practice Address - Phone:617-860-6333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856299122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist