Healthcare Provider Details

I. General information

NPI: 1467085498
Provider Name (Legal Business Name): MACIEJ KOSAKOWSKI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MATT KOSAKOWSKI DMD

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BRIDGETOWN PIKE
FEASTERVILLE TREVOSE PA
19053-4326
US

IV. Provider business mailing address

435 E 70TH ST APT 31A
NEW YORK NY
10021-5350
US

V. Phone/Fax

Practice location:
  • Phone: 215-322-7810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS044537
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: