Healthcare Provider Details

I. General information

NPI: 1902925449
Provider Name (Legal Business Name): CHRISTOPHER WALTER KOTERWAS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E PULASKI HWY
ELKTON MD
21921-6067
US

IV. Provider business mailing address

401 E PULASKI HWY
ELKTON MD
21921-6067
US

V. Phone/Fax

Practice location:
  • Phone: 410-392-3737
  • Fax: 410-392-3738
Mailing address:
  • Phone: 410-392-3737
  • Fax: 410-392-3738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6583
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: