=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083153985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLE OMS LAKEWOOD/ROCKY RIVER - JEFFREY W. KOSMAN DDS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2017
-----------------------------------------------------
Last Update Date | 02/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15711 MADISON AVE SUITE 104
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44107-5655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-228-9000
-----------------------------------------------------
Fax | 216-228-8280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15711 MADISON AVE SUITE 104
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44107-5655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-228-9000
-----------------------------------------------------
Fax | 216-228-8280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY W. KOSMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 440-934-2626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 30020221
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------