Healthcare Provider Details

I. General information

NPI: 1629094222
Provider Name (Legal Business Name): KOTARY, DETAR & ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/09/2007
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 TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS030572L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS016742L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS031506L
License Number StatePA

VIII. Authorized Official

Name: DR. EDMOND M KOTARY
Title or Position: DENTIST
Credential: D.M.D.
Phone: 814-238-2431