Provider Demographics
NPI:1750510301
Name:KOSTEN, KATHRYN RAE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:RAE
Last Name:KOSTEN
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 1:2800 COLLEGE AVE
Mailing Address - Street 2:BLDG 263 RM 1102
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4742
Mailing Address - Country:US
Mailing Address - Phone:618-474-7095
Mailing Address - Fax:618-474-7083
Practice Address - Street 1:2800 COLLEGE AVE
Practice Address - Street 2:BLDG 263 RM 1102
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4742
Practice Address - Country:US
Practice Address - Phone:618-474-7095
Practice Address - Fax:618-474-7083
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-03
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009016931122300000X
IL019027990122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist