Healthcare Provider Details

I. General information

NPI: 1780611392
Provider Name (Legal Business Name): JOHN J KOZICKI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 ROCHESTER RD
TROY MI
48085-4951
US

IV. Provider business mailing address

4770 ROCHESTER RD
TROY MI
48085-4951
US

V. Phone/Fax

Practice location:
  • Phone: 248-689-9191
  • Fax: 248-689-5636
Mailing address:
  • Phone: 248-689-9191
  • Fax: 248-689-5636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number015334
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: