Provider Demographics
NPI:1740276104
Name:KOZICKI, THOMAS D (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:D
Last Name:KOZICKI
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 EAST MAIN
Mailing Address - Street 2:
Mailing Address - City:CENTERBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43011-0881
Mailing Address - Country:US
Mailing Address - Phone:740-625-6643
Mailing Address - Fax:740-625-9777
Practice Address - Street 1:9 EAST MAIN
Practice Address - Street 2:
Practice Address - City:CENTERBURG
Practice Address - State:OH
Practice Address - Zip Code:43011-0881
Practice Address - Country:US
Practice Address - Phone:740-625-6643
Practice Address - Fax:740-625-9777
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH174871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice