Provider Demographics
NPI:1144079823
Name:KOSMALSKI, GABRIEL (DDS)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:KOSMALSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6953 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:RUDOLPH
Mailing Address - State:WI
Mailing Address - Zip Code:54475-9516
Mailing Address - Country:US
Mailing Address - Phone:715-347-0612
Mailing Address - Fax:
Practice Address - Street 1:12200 WESTERN AVE STE 108
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-1493
Practice Address - Country:US
Practice Address - Phone:708-385-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001702151223G0001X
IL0190356131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice