Healthcare Provider Details

I. General information

NPI: 1912053422
Provider Name (Legal Business Name): LAWRENCE JOSEPH KOTOK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16342 COUNTY RD 30
MAPLE GROVE MN
55311
US

IV. Provider business mailing address

16342 COUNTY RD 30
MAPLE GROVE MN
55311
US

V. Phone/Fax

Practice location:
  • Phone: 763-420-9876
  • Fax: 763-420-2354
Mailing address:
  • Phone: 763-420-9876
  • Fax: 763-420-2354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9661
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: