Provider Demographics
NPI:1477639250
Name:COZART, WILEY SIMEON III (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILEY
Middle Name:SIMEON
Last Name:COZART
Suffix:III
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 1:344 GALLIMORE RD
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-8874
Mailing Address - Country:US
Mailing Address - Phone:828-884-4433
Mailing Address - Fax:828-884-7875
Practice Address - Street 1:344 GALLIMORE RD
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-8874
Practice Address - Country:US
Practice Address - Phone:828-884-4433
Practice Address - Fax:828-884-7875
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC91840Medicaid
NC91840Medicaid