Healthcare Provider Details

I. General information

NPI: 1285086009
Provider Name (Legal Business Name): RUSSELL PERRY KOTCH D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 07/05/2016
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:
Mailing address:
  • Phone: 954-437-4443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN21881
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: