MEDICARE: OLIVIA CZAJKOWSKI

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	2901600112	MI

General Provider Information

NPI Number	:	1821650896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA CZAJKOWSKI

Provider Business Mailing Address
First Line	:	16199 MAPLEWOOD CT
Second Line	:
City	:	NORTHVILLE
State	:	MI
Zip	:	48168-2398
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	24415 W WARREN ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-2223
Country	:	US
Telephone Number	:	313-278-4470
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2019
Last Update Date	:	07/01/2019

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