Healthcare Provider Details

I. General information

NPI: 1508903063
Provider Name (Legal Business Name): MARK KOZLOWSKI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MAREK KOZLOWSKI

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W WALLINGS RD SUITE D
BROADVIEW HTS OH
44147-1200
US

IV. Provider business mailing address

1000 W WALLINGS RD SUITE D
BROADVIEW HTS OH
44147-1200
US

V. Phone/Fax

Practice location:
  • Phone: 440-546-9522
  • Fax: 440-546-9564
Mailing address:
  • Phone: 440-546-9522
  • Fax: 440-546-9564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30016184
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: