Provider Demographics
NPI:1932496544
Name:KOZLAK, SCOTT THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:THOMAS
Last Name:KOZLAK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 CONNECTICUT BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3013
Mailing Address - Country:US
Mailing Address - Phone:860-528-1359
Mailing Address - Fax:860-290-4142
Practice Address - Street 1:94 CONNECTICUT BLVD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3013
Practice Address - Country:US
Practice Address - Phone:860-528-1359
Practice Address - Fax:860-290-4142
Is Sole Proprietor?:No
Enumeration Date:2011-07-03
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT108351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice