Healthcare Provider Details

I. General information

NPI: 1194894253
Provider Name (Legal Business Name): RANDY KOVICAK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9944 CHAPEL HILL RD
MORRISVILLE NC
27560-9397
US

IV. Provider business mailing address

935 W NORTON AVE
MUSKEGON MI
49441-4195
US

V. Phone/Fax

Practice location:
  • Phone: 919-238-7649
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901017680
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10917
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: