Healthcare Provider Details

I. General information

NPI: 1174722839
Provider Name (Legal Business Name): MICHAEL KOWALIK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 W 79TH ST
BURBANK IL
60459-1161
US

IV. Provider business mailing address

6320 W 79TH ST
BURBANK IL
60459-1161
US

V. Phone/Fax

Practice location:
  • Phone: 708-599-3333
  • Fax: 708-599-1017
Mailing address:
  • Phone: 708-599-3333
  • Fax: 708-599-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: