Healthcare Provider Details

I. General information

NPI: 1801986187
Provider Name (Legal Business Name): MARK H. KOWAL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11045 BROADWAY SUITE C
CROWN POINT IN
46307-7473
US

IV. Provider business mailing address

11045 BROADWAY SUITE C
CROWN POINT IN
46307-7473
US

V. Phone/Fax

Practice location:
  • Phone: 219-661-1119
  • Fax:
Mailing address:
  • Phone: 219-661-1119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12008586A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: