Healthcare Provider Details

I. General information

NPI: 1770640336
Provider Name (Legal Business Name): MARK ALOYSIUS KOZLOWSKI D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NORWICH NEW LONDON TPKE
UNCASVILLE CT
06382-2121
US

IV. Provider business mailing address

PO BOX 566
UNCASVILLE CT
06382-0566
US

V. Phone/Fax

Practice location:
  • Phone: 860-848-1291
  • Fax: 860-848-9238
Mailing address:
  • Phone: 860-848-1291
  • Fax: 860-848-9238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number006200
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: