MEDICARE: DR. THOMAS D. KOZICKI DDS, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	17487	OH

General Provider Information

NPI Number	:	1740276104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS D. KOZICKI DDS, MS

Provider Business Mailing Address
First Line	:	9 EAST MAIN
Second Line	:
City	:	CENTERBURG
State	:	OH
Zip	:	43011-0881
Country	:	US
Telephone Number	:	740-625-6643
Fax Number	:	740-625-9777

Provider Business Practice Location Address
First Line	:	9 EAST MAIN
Second Line	:
City	:	CENTERBURG
State	:	OH
Zip	:	43011-0881
Country	:	US
Telephone Number	:	740-625-6643
Fax Number	:	740-625-9777

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	07/08/2007

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