Provider Demographics
NPI:1851466064
Name:COSENTINO, STEPHEN JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JAMES
Last Name:COSENTINO
Suffix:
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 1:1215 DOCTORS DRIVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-592-8152
Mailing Address - Fax:903-592-7583
Practice Address - Street 1:1215 DOCTORS DRIVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-592-8152
Practice Address - Fax:903-592-7583
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX150261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
865734OtherUNITED CONCORDIA
TX126700705Medicaid
TX126700702Medicaid
TX126700702Medicaid
U28133Medicare UPIN