Provider Demographics
NPI:1104942986
Name:COSMAN, GLEN ROBERT
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:ROBERT
Last Name:COSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E 54TH ST APT 3C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4838
Mailing Address - Country:US
Mailing Address - Phone:718-745-4422
Mailing Address - Fax:718-745-8558
Practice Address - Street 1:7815 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3703
Practice Address - Country:US
Practice Address - Phone:718-745-4422
Practice Address - Fax:718-745-8558
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist