Provider Demographics
NPI:1881754844
Name:COSIMI, MICHAEL (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:COSIMI
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 LINCOLN DR STE C
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3790
Mailing Address - Country:US
Mailing Address - Phone:618-997-2403
Mailing Address - Fax:
Practice Address - Street 1:408 LINCOLN DR STE C
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3790
Practice Address - Country:US
Practice Address - Phone:618-997-2403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210022401223P0300X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics