MEDICARE: COSMIC DENTAL PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1275312068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COSMIC DENTAL PLLC

Provider Business Mailing Address
First Line	:	1502 S WESTMORELAND RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75211-5765
Country	:	US
Telephone Number	:	904-729-2866
Fax Number	:

Provider Business Practice Location Address
First Line	:	1502 S WESTMORELAND RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75211-5765
Country	:	US
Telephone Number	:	904-729-2866
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	SERGE MECHREK
Credential	:
Telephone Number	:	904-729-2866

Provider Enumeration Date	:	09/21/2023
Last Update Date	:	10/23/2023

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