Healthcare Provider Details

I. General information

NPI: 1689798878
Provider Name (Legal Business Name): IRA M KOTCH D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SW 129TH AVE SUITE 302
PEMBROKE PINES FL
33027-1761
US

IV. Provider business mailing address

1 SW 129TH AVE SUITE 302
PEMBROKE PINES FL
33027-1761
US

V. Phone/Fax

Practice location:
  • Phone: 954-437-4443
  • Fax: 954-437-5642
Mailing address:
  • Phone: 954-437-4443
  • Fax: 954-437-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10090
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: