Healthcare Provider Details

I. General information

NPI: 1861475410
Provider Name (Legal Business Name): TAMARA E.B. KOSS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 09/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 CANTERBURY DRIVE
INDIALANTIC FL
32903-4027
US

IV. Provider business mailing address

1990 CANTERBURY DR
INDIALANTIC FL
32903-4027
US

V. Phone/Fax

Practice location:
  • Phone: 321-952-3868
  • Fax: 321-952-3868
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 13909
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: