Provider Demographics
NPI:1629329198
Name:AMHERST ORAL SURGERY AND IMPLANT CENTER LLC
Entity Type:Organization
Organization Name:AMHERST ORAL SURGERY AND IMPLANT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:KOSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-988-3400
Mailing Address - Street 1:550 N LEAVITT RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1131
Mailing Address - Country:US
Mailing Address - Phone:440-988-3400
Mailing Address - Fax:440-988-3405
Practice Address - Street 1:550 N LEAVITT RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1131
Practice Address - Country:US
Practice Address - Phone:440-988-3400
Practice Address - Fax:440-988-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350999121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0065520Medicaid