Provider Demographics
NPI:1508903063
Name:KOZLOWSKI, MARK (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KOZLOWSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MAREK
Other - Middle Name:
Other - Last Name:KOZLOWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1000 W WALLINGS RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:BROADVIEW HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-1200
Mailing Address - Country:US
Mailing Address - Phone:440-546-9522
Mailing Address - Fax:440-546-9564
Practice Address - Street 1:1000 W WALLINGS RD
Practice Address - Street 2:SUITE D
Practice Address - City:BROADVIEW HTS
Practice Address - State:OH
Practice Address - Zip Code:44147-1200
Practice Address - Country:US
Practice Address - Phone:440-546-9522
Practice Address - Fax:440-546-9564
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300161841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice