Provider Demographics
NPI:1154814804
Name:COSSICH, DIMETRY BENEDICT JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIMETRY
Middle Name:BENEDICT
Last Name:COSSICH
Suffix:JR
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 1:14165 S LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435-5765
Mailing Address - Country:US
Mailing Address - Phone:504-975-5015
Mailing Address - Fax:
Practice Address - Street 1:842 COLLINS BLVD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2759
Practice Address - Country:US
Practice Address - Phone:985-809-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA68881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice