Healthcare Provider Details

I. General information

NPI: 1275684706
Provider Name (Legal Business Name): JAMES J KOZAK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8685 LA MESA BLVD # F
LA MESA CA
91941-3903
US

IV. Provider business mailing address

8685 LA MESA BLVD # F
LA MESA CA
91941-3903
US

V. Phone/Fax

Practice location:
  • Phone: 619-463-0393
  • Fax: 619-463-8346
Mailing address:
  • Phone: 619-463-0393
  • Fax: 619-463-8346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30086
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: