Basic Information
| Provider Information | |||||||||
| NPI: | 1386052579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSIBA | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG 38717 38TH STREET | ||||||||
| Address2: | USA DENTAC | ||||||||
| City: | FT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | 7067872082 | ||||||||
| Practice Location | |||||||||
| Address1: | BLD128 CHAFFEE ROAD | ||||||||
| Address2: | USA DENTAL HEALTH ACTIVITY | ||||||||
| City: | FT BLISS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157425935 | ||||||||
| FaxNumber: | 9157425174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2014 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9936 | TN | Y | Dental Providers | Dentist | General Practice |
No ID Information.