Provider Demographics
NPI:1649326786
Name:KOZINA, GUSTAV R (DDS)
Entity type:Individual
Prefix:DR
First Name:GUSTAV
Middle Name:R
Last Name:KOZINA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37179 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60087-3154
Mailing Address - Country:US
Mailing Address - Phone:847-689-3800
Mailing Address - Fax:
Practice Address - Street 1:2127 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-2801
Practice Address - Country:US
Practice Address - Phone:847-689-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019127391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice