Healthcare Provider Details

I. General information

NPI: 1063403624
Provider Name (Legal Business Name): MITCHELL A COHEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 AMHERST ST
LAKE GEORGE NY
12845-1219
US

IV. Provider business mailing address

48 AMHERST ST PO BOX 232
LAKE GEORGE NY
12845-1219
US

V. Phone/Fax

Practice location:
  • Phone: 518-668-4024
  • Fax: 518-668-2140
Mailing address:
  • Phone: 518-668-4024
  • Fax: 518-668-2140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number040361-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: