MEDICARE: MANHATTAN BOULEVARD DENTAL ASSOCIATES, A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	122300000X	Dentist
2	1223E0200X	Endodontics
3	1223P0221X	Pediatric Dentistry
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
5	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1750750360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANHATTAN BOULEVARD DENTAL ASSOCIATES, A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	1708 MANHATTAN BLVD
Second Line	:	SUITE C
City	:	HARVEY
State	:	LA
Zip	:	70058-3400
Country	:	US
Telephone Number	:	504-361-5333
Fax Number	:

Provider Business Practice Location Address
First Line	:	1090 NORTHCHASE PKWY SE
Second Line	:	STE 150
City	:	MARIETTA
State	:	GA
Zip	:	30067-6405
Country	:	US
Telephone Number	:	770-916-5031
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DIMETRY COSSICH
Credential	:	DDS
Telephone Number	:	504-361-5333

Provider Enumeration Date	:	09/24/2015
Last Update Date	:	09/24/2015

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