Healthcare Provider Details

I. General information

NPI: 1932373032
Provider Name (Legal Business Name): BROOKLYN BLVD. DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5831 BROOKLYN BLVD
BROOKLYN CENTER MN
55429-2521
US

IV. Provider business mailing address

5831 BROOKLYN BLVD
BROOKLYN CENTER MN
55429-2521
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 Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateMN

VIII. Authorized Official

Name: DR. WILLIAM SAM KOTONIAS
Title or Position: DENTIST/OWNER
Credential: D.D.S.
Phone: 763-533-8669