Healthcare Provider Details

I. General information

NPI: 1043291008
Provider Name (Legal Business Name): STELLA A KOSIBOROP DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7410 35TH AVE STE 106W
JACKSON HTS NY
11372-8160
US

IV. Provider business mailing address

7410 35TH AVE STE 106W
JACKSON HTS NY
11372-8160
US

V. Phone/Fax

Practice location:
  • Phone: 718-426-4040
  • Fax:
Mailing address:
  • Phone: 718-426-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0451691
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: