Healthcare Provider Details

I. General information

NPI: 1053609115
Provider Name (Legal Business Name): DR. SCOTT KOTTEMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13998 MAPLE KNOLL WAY SUITE 102
MAPLE GROVE MN
55369-7004
US

IV. Provider business mailing address

13998 MAPLE KNOLL WAY SUITE 102
MAPLE GROVE MN
55369-7004
US

V. Phone/Fax

Practice location:
  • Phone: 763-420-6834
  • Fax:
Mailing address:
  • Phone: 763-420-6834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD12737
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: