Provider Demographics
NPI:1316026552
Name:KOSCIUK, PAUL E (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:KOSCIUK
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 1:6565 BALBOA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3154
Mailing Address - Country:US
Mailing Address - Phone:858-729-2122
Mailing Address - Fax:858-279-5495
Practice Address - Street 1:6565 BALBOA AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3154
Practice Address - Country:US
Practice Address - Phone:858-729-2122
Practice Address - Fax:858-279-5495
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA365681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice