MEDICARE: THOMAS J KOSICK D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	031319	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1495660	OTHER	PA	UNITED CONCORDIA PROVIDER

General Provider Information

NPI Number	:	1104827476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS J KOSICK D.M.D.

Provider Business Mailing Address
First Line	:	PO BOX 487
Second Line	:
City	:	SANDY LAKE
State	:	PA
Zip	:	16145-0487
Country	:	US
Telephone Number	:	724-376-7161
Fax Number	:

Provider Business Practice Location Address
First Line	:	3242 S. MAIN ST
Second Line	:
City	:	SANDY LAKE
State	:	PA
Zip	:	16145-0487
Country	:	US
Telephone Number	:	724-376-7161
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	10/15/2013

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