Provider Demographics
NPI:1952537821
Name:COS, EDWARD (DMD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:COS
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 1:365 WILLLARD AVENUE
Mailing Address - Street 2:SUITE 2H
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111
Mailing Address - Country:US
Mailing Address - Phone:860-667-8277
Mailing Address - Fax:
Practice Address - Street 1:365 WILLLARD AVENUE
Practice Address - Street 2:SUITE 2H
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111
Practice Address - Country:US
Practice Address - Phone:860-667-8277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT104861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1952537821Medicaid