Provider Demographics
NPI:1215345939
Name:MARK KOLOZENSKI, DDS, MS, PC
Entity type:Organization
Organization Name:MARK KOLOZENSKI, DDS, MS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOLOZENSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-201-1000
Mailing Address - Street 1:10083 W LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1272
Mailing Address - Country:US
Mailing Address - Phone:815-201-1000
Mailing Address - Fax:815-201-1111
Practice Address - Street 1:10083 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1272
Practice Address - Country:US
Practice Address - Phone:815-201-1000
Practice Address - Fax:815-201-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210016691223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty