Provider Demographics
NPI:1710127295
Name:KOSEL, ERIC BERNARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:BERNARD
Last Name:KOSEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SUPPIGER WAY #3
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249
Mailing Address - Country:US
Mailing Address - Phone:618-654-4551
Mailing Address - Fax:708-532-2917
Practice Address - Street 1:380 SUPPIGER WAY #3
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249
Practice Address - Country:US
Practice Address - Phone:618-654-4551
Practice Address - Fax:708-532-2917
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0258811223G0001X
IL019.025881122300000X
MO2018009394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice