Provider Demographics
NPI:1174933162
Name:MYSTIC WESTERLY ORTHODONTICS, PC
Entity type:Organization
Organization Name:MYSTIC WESTERLY ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:KOZLOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-442-4421
Mailing Address - Street 1:117 COW HILL RD
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1449
Mailing Address - Country:US
Mailing Address - Phone:860-536-9661
Mailing Address - Fax:
Practice Address - Street 1:117 COW HILL RD
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1449
Practice Address - Country:US
Practice Address - Phone:860-536-9661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT83761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty