Healthcare Provider Details

I. General information

NPI: 1174933162
Provider Name (Legal Business Name): MYSTIC WESTERLY ORTHODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 COW HILL RD
MYSTIC CT
06355-1449
US

IV. Provider business mailing address

117 COW HILL RD
MYSTIC CT
06355-1449
US

V. Phone/Fax

Practice location:
  • Phone: 860-536-9661
  • Fax:
Mailing address:
  • Phone: 860-536-9661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8376
License Number StateCT

VIII. Authorized Official

Name: DR. JEFFREY TODD KOZLOWSKI
Title or Position: PRESIDENT
Credential: DDS
Phone: 860-442-4421