Healthcare Provider Details

I. General information

NPI: 1215065552
Provider Name (Legal Business Name): STEPHEN J KOTKIS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 HOLLYWOOD BLVD
HOLLYWOOD FL
33021-6749
US

IV. Provider business mailing address

3939 HOLLYWOOD BLVD
HOLLYWOOD FL
33021-6749
US

V. Phone/Fax

Practice location:
  • Phone: 954-989-5566
  • Fax: 954-989-5567
Mailing address:
  • Phone: 954-989-5566
  • Fax: 954-989-5567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN5867
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: