=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952337685
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK FRANKLIN KOZACKO DDS PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 6836
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------