MEDICARE: DR. RENAE BRADDY KOSHA DDS

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	11359	NC
2	122300000X	Dentist	11359	NC

General Provider Information

NPI Number	:	1447817770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RENAE BRADDY KOSHA DDS

Provider Business Mailing Address
First Line	:	103 MIMOSA PARK DR
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27534-3225
Country	:	US
Telephone Number	:	252-945-8781
Fax Number	:

Provider Business Practice Location Address
First Line	:	2821 NC-903 #093
Second Line	:
City	:	MAURY
State	:	NC
Zip	:	28554
Country	:	US
Telephone Number	:	252-653-5765
Fax Number	:

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

Provider Enumeration Date	:	05/22/2019
Last Update Date	:	06/06/2024

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