Healthcare Provider Details

I. General information

NPI: 1902963523
Provider Name (Legal Business Name): CHRISTOPHER MATTHEW KOTERWAS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16034 THREE NOTCH RD
CALIFORNIA MD
20619-3106
US

IV. Provider business mailing address

5525 BEACH DR
SAINT LEONARD MD
20685-2255
US

V. Phone/Fax

Practice location:
  • Phone: 301-863-7424
  • Fax: 301-863-6916
Mailing address:
  • Phone: 410-586-8674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13619
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: