=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487700555
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | G R KOZINA, DDS & ASSOC, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2127 GREEN BAY RD
-----------------------------------------------------
City | NORTH CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60064-2801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-689-3800
-----------------------------------------------------
Fax | 847-689-0191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1404
-----------------------------------------------------
City | NORTH CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60064-8404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-689-3800
-----------------------------------------------------
Fax | 847-689-0191
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MS. LAURA FORMICOLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-689-3800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------