Provider Demographics
NPI:1538141502
Name:KOZLOWSKI, LEO (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:
Last Name:KOZLOWSKI
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 1:1704 AVENUE J
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-3807
Mailing Address - Country:US
Mailing Address - Phone:718-252-3090
Mailing Address - Fax:718-377-3474
Practice Address - Street 1:1704 AVENUE J
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-3807
Practice Address - Country:US
Practice Address - Phone:718-252-3090
Practice Address - Fax:718-377-3474
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039937-011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01049774Medicaid