Healthcare Provider Details

I. General information

NPI: 1558355529
Provider Name (Legal Business Name): GARY EDWARD KOTERWAS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19414 LEITERSBURG PIKE
HAGERSTOWN MD
21742-7601
US

IV. Provider business mailing address

19414 LEITERSBURG PIKE
HAGERSTOWN MD
21742-7601
US

V. Phone/Fax

Practice location:
  • Phone: 301-791-1700
  • Fax: 301-791-9257
Mailing address:
  • Phone: 301-791-1700
  • Fax: 301-791-9257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11375
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: