Provider Demographics
NPI:1851130348
Name:KOSZYKOWSKI, JACK (DDS)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KOSZYKOWSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7205 W 34TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-4531
Mailing Address - Country:US
Mailing Address - Phone:918-710-1876
Mailing Address - Fax:
Practice Address - Street 1:101 E CEDAR CREEK DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-9548
Practice Address - Country:US
Practice Address - Phone:918-358-3512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK78731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice