Healthcare Provider Details

I. General information

NPI: 1265655963
Provider Name (Legal Business Name): WILLIAM SAM KOTONIAS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5831 BROOKLYN BLVD
BROOKLYN CENTER MN
55429
US

IV. Provider business mailing address

5831 BROOKLYN BLVD
BROOKLYN CENTER MN
55429
US

V. Phone/Fax

Practice location:
  • Phone: 763-533-8669
  • Fax: 763-533-8716
Mailing address:
  • Phone: 763-533-8669
  • Fax: 763-533-8716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10360
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: