Healthcare Provider Details

I. General information

NPI: 1194353888
Provider Name (Legal Business Name): MICHAEL EDWARD COTTERELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC 06-3500 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

MSC 06-3500 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-4030
  • Fax:
Mailing address:
  • Phone: 505-925-4030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS043475
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: