Healthcare Provider Details

I. General information

NPI: 1275909467
Provider Name (Legal Business Name): GEORGIOS KOTSAKIS DDS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BERGEN STREET
NEWARK NJ
07103
US

IV. Provider business mailing address

110 BERGEN STREET D800
NEWARK NJ
07103
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-4242
  • Fax:
Mailing address:
  • Phone: 973-972-7224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDF60582867
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number01644
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: