Provider Demographics
NPI:1083784367
Name:KOZEK, MICHAEL A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:KOZEK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4647 W. 103RD STREET
Mailing Address - Street 2:SUITE 2-I
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4793
Mailing Address - Country:US
Mailing Address - Phone:708-423-0500
Mailing Address - Fax:708-423-0501
Practice Address - Street 1:4647 W 103RD ST
Practice Address - Street 2:SUITE 2-I
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4779
Practice Address - Country:US
Practice Address - Phone:708-423-0500
Practice Address - Fax:708-423-0501
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice