Provider Demographics
NPI:1114103066
Name:MARK KOZACKO DDS PA
Entity Type:Organization
Organization Name:MARK KOZACKO DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:KOZACKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-848-9871
Mailing Address - Street 1:6817 FALLS OF NEUSE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5386
Mailing Address - Country:US
Mailing Address - Phone:919-848-9871
Mailing Address - Fax:919-848-7841
Practice Address - Street 1:6817 FALLS OF NEUSE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5386
Practice Address - Country:US
Practice Address - Phone:919-848-9871
Practice Address - Fax:919-848-7841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899016WMedicaid
NC1C2428853Medicare UPIN
NC1C2428872Medicare UPIN
NC899016WMedicaid
NCU90388Medicare UPIN