MEDICARE: DR. GABRIEL KOSMALSKI DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	600170215	WI
2	1223G0001X	General Practice Dentistry	019035613	IL

General Provider Information

NPI Number	:	1144079823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GABRIEL KOSMALSKI DDS

Provider Business Mailing Address
First Line	:	6953 HILLCREST AVE
Second Line	:
City	:	RUDOLPH
State	:	WI
Zip	:	54475-9516
Country	:	US
Telephone Number	:	715-347-0612
Fax Number	:

Provider Business Practice Location Address
First Line	:	12200 WESTERN AVE STE 108
Second Line	:
City	:	BLUE ISLAND
State	:	IL
Zip	:	60406-1493
Country	:	US
Telephone Number	:	708-385-3700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2024
Last Update Date	:	11/20/2024

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