Healthcare Provider Details

I. General information

NPI: 1174797997
Provider Name (Legal Business Name): EDMOND MORRIS KOTARY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 SANDY DR
STATE COLLEGE PA
16803-2515
US

IV. Provider business mailing address

2014 SANDY DR
STATE COLLEGE PA
16803-2515
US

V. Phone/Fax

Practice location:
  • Phone: 814-238-2431
  • Fax: 814-235-6881
Mailing address:
  • Phone: 814-238-2431
  • Fax: 814-235-6881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS030572-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: