Provider Demographics
NPI:1508916073
Name:COSSAR, JAN M (DMD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:M
Last Name:COSSAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WATERFORD SQUARE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:601-856-9779
Mailing Address - Fax:601-856-9120
Practice Address - Street 1:204 WATERFORD SQUARE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-856-9779
Practice Address - Fax:601-856-9120
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2645-911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice