Healthcare Provider Details

I. General information

NPI: 1215159413
Provider Name (Legal Business Name): JOHN WILLIAM KOTARSKI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 LIBERTY ST SUITE 306
SPRINGFIELD MA
01103-1114
US

IV. Provider business mailing address

125 LIBERTY ST SUITE 306
SPRINGFIELD MA
01103-1114
US

V. Phone/Fax

Practice location:
  • Phone: 413-733-6611
  • Fax:
Mailing address:
  • Phone: 413-733-6611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9094
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: