Healthcare Provider Details

I. General information

NPI: 1558097709
Provider Name (Legal Business Name): ANDREW KOTLARZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 N PERIMETER RD
MALMSTROM AFB MT
59402-6701
US

IV. Provider business mailing address

7300 N PERIMETER RD
MALMSTROM AFB MT
59402-6701
US

V. Phone/Fax

Practice location:
  • Phone: 406-731-4633
  • Fax:
Mailing address:
  • Phone: 406-731-4633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12939519-9921
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN-DEN-LIC-27530
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: