Healthcare Provider Details

I. General information

NPI: 1164754016
Provider Name (Legal Business Name): KOZAK ORTHODONTICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1326 MAIN ST SUITE B
ANTIOCH IL
60002-2181
US

IV. Provider business mailing address

1326 MAIN ST SUITE B
ANTIOCH IL
60002-2181
US

V. Phone/Fax

Practice location:
  • Phone: 847-603-1682
  • Fax:
Mailing address:
  • Phone: 847-603-1682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number19-025556
License Number StateIL

VIII. Authorized Official

Name: DR. BRYON R KOZAK
Title or Position: ORTHODONTIST
Credential: DDS, MS
Phone: 847-603-1682