Provider Demographics
NPI:1679758395
Name:KOSMEN, JOHN MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:KOSMEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548
Mailing Address - Country:US
Mailing Address - Phone:715-358-3321
Mailing Address - Fax:
Practice Address - Street 1:9762 WEST LAKE AVENUE
Practice Address - Street 2:
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548
Practice Address - Country:US
Practice Address - Phone:715-358-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4694122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33727700Medicaid
79134Medicare PIN
WI33727700Medicaid