Healthcare Provider Details

I. General information

NPI: 1114103066
Provider Name (Legal Business Name): MARK KOZACKO DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6817 FALLS OF NEUSE RD SUITE 101
RALEIGH NC
27615-5386
US

IV. Provider business mailing address

6817 FALLS OF NEUSE RD SUITE 101
RALEIGH NC
27615-5386
US

V. Phone/Fax

Practice location:
  • Phone: 919-848-9871
  • Fax: 919-848-7841
Mailing address:
  • Phone: 919-848-9871
  • Fax: 919-848-7841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK FRANKLIN KOZACKO
Title or Position: PRESIDENT
Credential: DDS
Phone: 919-848-9871