Provider Demographics
NPI:1457850687
Name:SELECT DENTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:SELECT DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOSEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-340-3423
Mailing Address - Street 1:1422 LINCOLN WAY E
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46613-3250
Mailing Address - Country:US
Mailing Address - Phone:574-232-8888
Mailing Address - Fax:574-232-8929
Practice Address - Street 1:1422 LINCOLN WAY E
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46613-3250
Practice Address - Country:US
Practice Address - Phone:574-232-8888
Practice Address - Fax:574-232-8929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120098731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12010354AOtherSTATE LICENSE
IN12012866AOtherSTATE LICENSE
IN200214390Medicaid