Healthcare Provider Details

I. General information

NPI: 1659682888
Provider Name (Legal Business Name): JACQUELINE M KOTULA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 UNION ST
SAN FRANCISCO CA
94123-4508
US

IV. Provider business mailing address

4050 REDWOOD HWY STE A
SAN RAFAEL CA
94903-5149
US

V. Phone/Fax

Practice location:
  • Phone: 415-474-1555
  • Fax:
Mailing address:
  • Phone: 415-499-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number59323
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: