Provider Demographics
NPI:1811064215
Name:DOUGLAS J KOSEK DDS PC
Entity type:Organization
Organization Name:DOUGLAS J KOSEK DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KOSEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-232-2992
Mailing Address - Street 1:413 WEST JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1514
Mailing Address - Country:US
Mailing Address - Phone:574-232-2992
Mailing Address - Fax:574-232-2739
Practice Address - Street 1:413 WEST JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1514
Practice Address - Country:US
Practice Address - Phone:574-232-2992
Practice Address - Fax:574-232-2739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120098731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty