Healthcare Provider Details

I. General information

NPI: 1649269705
Provider Name (Legal Business Name): KRIS KOTSAY DENTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 BLACK ROCK AVE
BRIDGEPORT CT
06605-1200
US

IV. Provider business mailing address

64 BLACK ROCK AVE
BRIDGEPORT CT
06605-1200
US

V. Phone/Fax

Practice location:
  • Phone: 203-579-5223
  • Fax: 203-332-0376
Mailing address:
  • Phone: 203-579-5223
  • Fax: 203-332-0376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number009330
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: