MEDICARE: DANIEL R. KOZICKI, DDS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist		IL

General Provider Information

NPI Number	:	1588742936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DANIEL R. KOZICKI, DDS, PC

Provider Business Mailing Address
First Line	:	4114 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-5008
Country	:	US
Telephone Number	:	773-581-0811
Fax Number	:	773-581-1530

Provider Business Practice Location Address
First Line	:	4114 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-5008
Country	:	US
Telephone Number	:	773-581-0811
Fax Number	:	773-581-1530

Authorized Official
Title or Position	:	PRESIDENT/DENTIST
Name	:	DR. DANIEL R. KOZICKI
Credential	:	DDS
Telephone Number	:	773-581-0811

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	01/29/2008

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