Provider Demographics
NPI:1306048111
Name:KOWALSKI, KEVIN C (LD)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:C
Last Name:KOWALSKI
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 LEIGH WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2403
Mailing Address - Country:US
Mailing Address - Phone:360-848-7614
Mailing Address - Fax:360-848-6355
Practice Address - Street 1:1521 LEIGH WAY
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2403
Practice Address - Country:US
Practice Address - Phone:360-848-7614
Practice Address - Fax:360-848-6355
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0254122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA891432OtherUNITED CONCORDIA
WA5032990Medicaid