Healthcare Provider Details

I. General information

NPI: 1265661417
Provider Name (Legal Business Name): MAULIK KOTDAWALA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1384 ATWOOD AVE
JOHNSTON RI
02919
US

IV. Provider business mailing address

PO BOX 3189
SYRACUSE NY
13220-3189
US

V. Phone/Fax

Practice location:
  • Phone: 401-943-0400
  • Fax:
Mailing address:
  • Phone: 866-273-8204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN03046
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: