Healthcare Provider Details

I. General information

NPI: 1295698546
Provider Name (Legal Business Name): JAKE KOSMAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N LEAVITT RD
AMHERST OH
44001-1128
US

IV. Provider business mailing address

4791 E LAKE RD
SHEFFIELD LAKE OH
44054-1436
US

V. Phone/Fax

Practice location:
  • Phone: 440-988-4166
  • Fax:
Mailing address:
  • Phone: 440-864-7924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.028196
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: