Healthcare Provider Details

I. General information

NPI: 1154696847
Provider Name (Legal Business Name): KOZA FAMILY DENTAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 COVE AVE STE D
LA GRANDE OR
97850-0407
US

IV. Provider business mailing address

2502 COVE AVE STE D
LA GRANDE OR
97850-0407
US

V. Phone/Fax

Practice location:
  • Phone: 541-963-4962
  • Fax: 541-963-4531
Mailing address:
  • Phone: 541-963-4962
  • Fax: 541-963-4531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8404
License Number StateOR

VIII. Authorized Official

Name: STEPHEN A KOZA
Title or Position: OWNER
Credential: DMD
Phone: 541-963-4962