MEDICARE: SELECT DENTAL ASSOCIATES PC

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	12009873	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12010354A	OTHER	IN	STATE LICENSE
2	12012866A	OTHER	IN	STATE LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457850687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELECT DENTAL ASSOCIATES PC

Provider Business Mailing Address
First Line	:	1422 LINCOLN WAY E
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46613-3250
Country	:	US
Telephone Number	:	574-232-8888
Fax Number	:	574-232-8929

Provider Business Practice Location Address
First Line	:	1422 LINCOLN WAY E
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46613-3250
Country	:	US
Telephone Number	:	574-232-8888
Fax Number	:	574-232-8929

Authorized Official
Title or Position	:	OWNER
Name	:	DOUGLAS J KOSEK
Credential	:	DDS
Telephone Number	:	574-340-3423

Provider Enumeration Date	:	02/02/2018
Last Update Date	:	02/02/2018

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