Healthcare Provider Details

I. General information

NPI: 1306048111
Provider Name (Legal Business Name): KEVIN C KOWALSKI L.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 LEIGH WAY SUITE A
MOUNT VERNON WA
98273-2403
US

IV. Provider business mailing address

1521 LEIGH WAY SUITE A
MOUNT VERNON WA
98273-2403
US

V. Phone/Fax

Practice location:
  • Phone: 360-848-7614
  • Fax: 360-848-6355
Mailing address:
  • Phone: 360-848-7614
  • Fax: 360-848-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number0254
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: