Provider Demographics
NPI:1164754016
Name:KOZAK ORTHODONTICS, P.C.
Entity Type:Organization
Organization Name:KOZAK ORTHODONTICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYON
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOZAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:847-603-1682
Mailing Address - Street 1:1326 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-2181
Mailing Address - Country:US
Mailing Address - Phone:847-603-1682
Mailing Address - Fax:
Practice Address - Street 1:1326 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-2181
Practice Address - Country:US
Practice Address - Phone:847-603-1682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0255561223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty