MEDICARE: KOSAL KOM, DDS, INC

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	41442	CA

General Provider Information

NPI Number	:	1689805012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOSAL KOM, DDS, INC

Provider Business Mailing Address
First Line	:	2338 E ANAHEIM ST
Second Line	:	SUITE 108
City	:	LONG BEACH
State	:	CA
Zip	:	90804-5730
Country	:	US
Telephone Number	:	562-434-9980
Fax Number	:

Provider Business Practice Location Address
First Line	:	2338 E ANAHEIM ST
Second Line	:	SUITE 108
City	:	LONG BEACH
State	:	CA
Zip	:	90804-5730
Country	:	US
Telephone Number	:	562-434-9980
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KOSAL KOM
Credential	:	DDS
Telephone Number	:	562-434-9980

Provider Enumeration Date	:	08/03/2009
Last Update Date	:	08/03/2009

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