Provider Demographics
NPI:1841287000
Name:KOSARAJU, AMAR (DMD)
Entity type:Individual
Prefix:DR
First Name:AMAR
Middle Name:
Last Name:KOSARAJU
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 1:1615 TRUEMPER ST
Mailing Address - Street 2:DUNN DENTAL CLINIC, RM B227
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236
Mailing Address - Country:US
Mailing Address - Phone:210-292-0774
Mailing Address - Fax:
Practice Address - Street 1:1615 TRUEMPER ST
Practice Address - Street 2:DUNN DENTAL CLINIC, RM B227
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-292-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-031024L1223G0001X
NY058340122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist