Healthcare Provider Details

I. General information

NPI: 1235668732
Provider Name (Legal Business Name): MATTHEW JAMES KOTAPISH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

16 CLARK PL
COLUMBUS OH
43201-2457
US

V. Phone/Fax

Practice location:
  • Phone: 614-688-3763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30025045
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: