Provider Demographics
NPI:1982751954
Name:KOKODYNSKI, R. ANDREW
Entity Type:Individual
Prefix:
First Name:R.
Middle Name:ANDREW
Last Name:KOKODYNSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 PARK DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-4586
Mailing Address - Country:US
Mailing Address - Phone:262-248-8346
Mailing Address - Fax:262-248-0130
Practice Address - Street 1:851 PARK DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4586
Practice Address - Country:US
Practice Address - Phone:262-248-8346
Practice Address - Fax:262-248-0130
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL47641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics