Healthcare Provider Details

I. General information

NPI: 1053458778
Provider Name (Legal Business Name): DOUGLAS E KOWALCZYK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

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

6481 NICHOLAS DR
COLUMBUS OH
43235-5204
US

IV. Provider business mailing address

8609 LAZELLE COMMONS DR
LEWIS CENTER OH
43035-8731
US

V. Phone/Fax

Practice location:
  • Phone: 614-799-9500
  • Fax:
Mailing address:
  • Phone: 614-209-6152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16839
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: