Provider Demographics
NPI:1952337685
Name:KOZACKO, MARK FRANKLIN (DDS PA)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:FRANKLIN
Last Name:KOZACKO
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6817 FALLS OF NEUSE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5386
Mailing Address - Country:US
Mailing Address - Phone:919-848-9871
Mailing Address - Fax:919-848-7841
Practice Address - Street 1:6817 FALLS OF NEUSE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5386
Practice Address - Country:US
Practice Address - Phone:919-848-9871
Practice Address - Fax:919-848-7841
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9016WOtherBCBS NC PROVIDER NUMBER
NC2428872Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
NCU90388Medicare UPIN
NC2428858Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL