# RANDY J KOVICAK, DDS, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1528547668
- **Authorized official:** ANDREW MATTA (OWNER)
- **Authorized official phone:** (231) 739-1300

## Contact information

- **Practice address:** 935 W NORTON AVE STE B, NORTON SHORES, MI 49441-4195
- **Practice address phone:** (231) 739-1300
- **Mailing address:** 11 S MILL ST STE 200, NEW CASTLE, PA 16101-3680

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | — | NULL | Yes |
| 122300000X | Dentist | — | — | Yes |

## Other

- **Enumeration date:** 08/09/2018
- **Last updated:** 08/09/2018