Healthcare Provider Details

I. General information

NPI: 1629329198
Provider Name (Legal Business Name): AMHERST ORAL SURGERY AND IMPLANT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N LEAVITT RD
AMHERST OH
44001-1131
US

IV. Provider business mailing address

550 N LEAVITT RD
AMHERST OH
44001-1131
US

V. Phone/Fax

Practice location:
  • Phone: 440-988-3400
  • Fax: 440-988-3405
Mailing address:
  • Phone: 440-988-3400
  • Fax: 440-988-3405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number35099912
License Number StateOH

VIII. Authorized Official

Name: JEFFREY W KOSMAN
Title or Position: OWNER
Credential: D.D.S.
Phone: 440-988-3400