Healthcare Provider Details

I. General information

NPI: 1508590647
Provider Name (Legal Business Name): JESSICA KOSTER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SAINT JOHNS MEDICAL PARK DR STE C
ST AUGUSTINE FL
32086-5202
US

IV. Provider business mailing address

130 SHIPYARD WAY APT 1436
SAINT AUGUSTINE FL
32084-4233
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-3715
  • Fax:
Mailing address:
  • Phone: 214-608-8046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number38796
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN29830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: