Provider Demographics
NPI:1720300155
Name:KOZAK, BERNADETTE (IPDH)
Entity type:Individual
Prefix:MS
First Name:BERNADETTE
Middle Name:
Last Name:KOZAK
Suffix:
Gender:F
Credentials:IPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:FRYEBURG
Mailing Address - State:ME
Mailing Address - Zip Code:04037-0523
Mailing Address - Country:US
Mailing Address - Phone:207-256-7606
Mailing Address - Fax:
Practice Address - Street 1:19 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:FRYEBURG
Practice Address - State:ME
Practice Address - Zip Code:04037-1205
Practice Address - Country:US
Practice Address - Phone:207-256-7606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-26
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERDH3183124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist