Healthcare Provider Details

I. General information

NPI: 1689262818
Provider Name (Legal Business Name): ALEKSEY KOZLOV, D.M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 01/04/2021
Certification Date: 12/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 BIRCH ROAD
CEDAR CREST NM
87008
US

IV. Provider business mailing address

13150 WENONAH AVE SE APT 521
ALBUQUERQUE NM
87123-3857
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-2622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ALEKSEY KOZLOV
Title or Position: MEMBER
Credential: DMD
Phone: 916-247-2048