MEDICARE: GLEN ROBERT COSMAN

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	122300000X	Dentist	36724	NY

General Provider Information

NPI Number	:	1104942986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN ROBERT COSMAN

Provider Business Mailing Address
First Line	:	220 E 54TH ST APT 3C
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-4838
Country	:	US
Telephone Number	:	718-745-4422
Fax Number	:	718-745-8558

Provider Business Practice Location Address
First Line	:	7815 5TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-3703
Country	:	US
Telephone Number	:	718-745-4422
Fax Number	:	718-745-8558

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/08/2007

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