Provider Demographics
NPI:1194891911
Name:MARK J KOLOSIONEK DDS & CARA L FAWCETT DDS INC
Entity type:Organization
Organization Name:MARK J KOLOSIONEK DDS & CARA L FAWCETT DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KOLOSIONEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-650-4558
Mailing Address - Street 1:45 MILFORD ROAD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236
Mailing Address - Country:US
Mailing Address - Phone:330-650-4558
Mailing Address - Fax:330-650-6466
Practice Address - Street 1:45 MILFORD ROAD
Practice Address - Street 2:SUITE 17
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236
Practice Address - Country:US
Practice Address - Phone:330-650-4558
Practice Address - Fax:330-650-6466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH18142122300000X
OH18058122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty