Healthcare Provider Details

I. General information

NPI: 1588834972
Provider Name (Legal Business Name): KOZAK ORTHODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E DEERPATH STE 280
LAKE FOREST IL
60045-1973
US

IV. Provider business mailing address

10320 75TH ST STE A
KENOSHA WI
53142-7525
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-4400
  • Fax:
Mailing address:
  • Phone: 262-697-8766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRYON R KOZAK
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 262-697-8766