=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114103066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK KOZACKO DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2008
-----------------------------------------------------
Last Update Date | 02/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6817 FALLS OF NEUSE RD SUITE 101
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27615-5386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-848-9871
-----------------------------------------------------
Fax | 919-848-7841
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6817 FALLS OF NEUSE RD SUITE 101
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27615-5386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-848-9871
-----------------------------------------------------
Fax | 919-848-7841
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARK FRANKLIN KOZACKO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 919-848-9871
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------