Healthcare Provider Details

I. General information

NPI: 1760640668
Provider Name (Legal Business Name): LARRY ALLEN KOZEK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N ROXBURY DRIVE SUITE 109
BEVERLY HILLS CA
90210
US

IV. Provider business mailing address

436 N ROXBURY DRIVE SUITE 109
BEVERLY HILLS CA
90210
US

V. Phone/Fax

Practice location:
  • Phone: 310-385-1311
  • Fax: 310-385-1377
Mailing address:
  • Phone: 310-385-1311
  • Fax: 310-385-1377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number24674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: