Healthcare Provider Details

I. General information

NPI: 1689233280
Provider Name (Legal Business Name): KOTHARY PROFESSIONAL DENTAL CORPORATION EZ DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 02/25/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 COTTLE RD STE 240
SAN JOSE CA
95123-3764
US

IV. Provider business mailing address

5669 LA SEYNE PL
SAN JOSE CA
95138-2240
US

V. Phone/Fax

Practice location:
  • Phone: 408-227-6000
  • Fax:
Mailing address:
  • Phone: 408-266-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. SAPANA KARSAN KOTHARY
Title or Position: OWNER, DENTIST
Credential: DDS
Phone: 408-227-6000