Healthcare Provider Details

I. General information

NPI: 1740613165
Provider Name (Legal Business Name): KOZLOWSKI ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 HEMPSTEAD STREET
NEW LONDON CT
06320
US

IV. Provider business mailing address

190 HEMPSTEAD STREET
NEW LONDON CT
06320
US

V. Phone/Fax

Practice location:
  • Phone: 860-442-4421
  • Fax: 866-837-6409
Mailing address:
  • Phone: 860-442-4421
  • Fax: 866-837-6409

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