Provider Demographics
NPI:1013006204
Name:KOSSAK-D'AGOSTINI, LYDIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:KOSSAK-D'AGOSTINI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1287
Mailing Address - Country:US
Mailing Address - Phone:313-642-0125
Mailing Address - Fax:586-268-1599
Practice Address - Street 1:850 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1287
Practice Address - Country:US
Practice Address - Phone:313-642-0125
Practice Address - Fax:586-268-1599
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI179361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice