Healthcare Provider Details

I. General information

NPI: 1699347039
Provider Name (Legal Business Name): OSSEO FAMILY DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CENTRAL AVE
OSSEO MN
55369-1241
US

IV. Provider business mailing address

30 CENTRAL AVE
OSSEO MN
55369-1241
US

V. Phone/Fax

Practice location:
  • Phone: 763-425-2626
  • Fax: 763-425-3070
Mailing address:
  • Phone: 763-425-2626
  • Fax: 763-425-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM KOTONIAS
Title or Position: DENTIST
Credential: DDS
Phone: 763-533-8669