Healthcare Provider Details

I. General information

NPI: 1215009220
Provider Name (Legal Business Name): IAN MICHAEL KOTT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 28TH ST SUITE 1
BOULDER CO
80303-1030
US

IV. Provider business mailing address

1440 28TH ST SUITE 1
BOULDER CO
80303-1030
US

V. Phone/Fax

Practice location:
  • Phone: 720-201-3869
  • Fax:
Mailing address:
  • Phone: 720-201-3869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9907
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: