Basic Information
Provider Information
NPI: 1396095287
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KOPACZ
FirstName: MOLLY
MiddleName: ELIZABETH
NamePrefix: DR.
NameSuffix:  
Credential: D.D.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 689 FEDERAL PKWY
Address2:  
City: LINDENHURST
State: IL
PostalCode: 600467838
CountryCode: US
TelephoneNumber: 5742612801
FaxNumber:  
Practice Location
Address1: 3001 GREEN BAY RD
Address2:  
City: NORTH CHICAGO
State: IL
PostalCode: 600643048
CountryCode: US
TelephoneNumber: 8476881900
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/18/2012
LastUpdateDate: 07/17/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223E0200X6875WIY Dental ProvidersDentistEndodontics

No ID Information.


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