Healthcare Provider Details

I. General information

NPI: 1477746659
Provider Name (Legal Business Name): LAWRENCE M KOTLER DDS MS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3543 WEST BRADDOCK RD SUITE E1 BRAD LEE OFFICE BUILDING
ALEXANDRIA VA
22301-1903
US

IV. Provider business mailing address

3543 WEST BRADDOCK RD SUITE E1 BRAD LEE OFFICE BUILDING
ALEXANDRIA VA
22301-1903
US

V. Phone/Fax

Practice location:
  • Phone: 703-931-6600
  • Fax: 703-931-4594
Mailing address:
  • Phone: 703-931-6600
  • Fax: 703-931-4594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401006677
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401004446
License Number StateVA

VIII. Authorized Official

Name: DR. LAWRENCE MARK KOTLER
Title or Position: OWNER
Credential: DDS MS
Phone: 703-931-6600