Provider Demographics
NPI:1831316157
Name:KOLOZENSKI, MARK A (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:KOLOZENSKI
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 1:14654 HOLLOW TREE RD
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-7402
Mailing Address - Country:US
Mailing Address - Phone:708-220-6640
Mailing Address - Fax:
Practice Address - Street 1:14654 HOLLOW TREE RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-7402
Practice Address - Country:US
Practice Address - Phone:708-220-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210016691223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics