Provider Demographics
NPI:1386651792
Name:KISIEL-COHEN, MICHELLE M (DMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:KISIEL-COHEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:E
Other - Last Name:MCCORMLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:3761 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:NY
Practice Address - Zip Code:12885-1837
Practice Address - Country:US
Practice Address - Phone:518-623-3918
Practice Address - Fax:518-623-4330
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043396122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02566127Medicaid
NY02566127Medicaid