=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346460441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWOODS ORAL AND MAXILLOFACIAL SURGERY SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2007
-----------------------------------------------------
Last Update Date | 09/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9762 WEST LAKE AVENUE
-----------------------------------------------------
City | MINOCQUA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-358-3321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1027
-----------------------------------------------------
City | MINOCQUA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-358-3321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | JOHN MICHAEL KOSMEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 715-358-3321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4694
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------