Healthcare Provider Details

I. General information

NPI: 1619967262
Provider Name (Legal Business Name): DAVID E KOSIOREK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 DWIGHT RD
LONGMEADOW MA
01106-1748
US

IV. Provider business mailing address

123 DWIGHT RD
LONGMEADOW MA
01106-1748
US

V. Phone/Fax

Practice location:
  • Phone: 413-567-1300
  • Fax: 413-525-3745
Mailing address:
  • Phone: 413-567-1300
  • Fax: 413-525-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number15133
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: