Provider Demographics
NPI:1588834972
Name:KOZAK ORTHODONTICS PC
Entity type:Organization
Organization Name:KOZAK ORTHODONTICS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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:262-697-8766
Mailing Address - Street 1:10320 75TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7525
Mailing Address - Country:US
Mailing Address - Phone:262-697-8766
Mailing Address - Fax:
Practice Address - Street 1:225 E DEERPATH STE 280
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1973
Practice Address - Country:US
Practice Address - Phone:847-234-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1104946912OtherNPI