Provider Demographics
NPI:1346460441
Name:NORTHWOODS ORAL AND MAXILLOFACIAL SURGERY SC
Entity Type:Organization
Organization Name:NORTHWOODS ORAL AND MAXILLOFACIAL SURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOSMEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-358-3321
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:53548
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4694122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33727700Medicaid
U56732Medicare UPIN
WI33727700Medicaid