Healthcare Provider Details

I. General information

NPI: 1659898203
Provider Name (Legal Business Name): MICHAEL R KOSSEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 08/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N 11TH ST
PHILADELPHIA PA
19123-1957
US

IV. Provider business mailing address

292 HOLSTEIN ROAD
GULPH MILLS PA
19428
US

V. Phone/Fax

Practice location:
  • Phone: 215-769-1594
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH013418L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: