Provider Demographics
NPI:1093973935
Name:KOWALCZYK, JAMES B
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:B
Last Name:KOWALCZYK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 N LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-2745
Mailing Address - Country:US
Mailing Address - Phone:847-546-4725
Mailing Address - Fax:847-546-4850
Practice Address - Street 1:1016 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-2745
Practice Address - Country:US
Practice Address - Phone:847-546-4725
Practice Address - Fax:847-546-4850
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019015397122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist