Healthcare Provider Details

I. General information

NPI: 1093973935
Provider Name (Legal Business Name): DR. JAMES B KOWALCZYK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 N LAKE SHORE DR
ROUND LAKE BEACH IL
60073-2745
US

IV. Provider business mailing address

1016 N LAKE SHORE DR
ROUND LAKE BEACH IL
60073-2745
US

V. Phone/Fax

Practice location:
  • Phone: 847-546-4725
  • Fax: 847-546-4850
Mailing address:
  • Phone: 847-546-4725
  • Fax: 847-546-4850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019015397
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: