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General NPI Number Information
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NPI Number | 1497378053
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Entity Type | Individual
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Provider Name | IVAN SERGEYEVICH KOUTSOPATRIY DDS
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Gender | Male
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Dates
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Enumeration Date | 05/18/2020
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Last Update Date | 10/30/2025
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Provider Practice Location Address
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Address Line | 2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
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City | FORT BRAGG
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State | NC
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Zip | 28310-0001
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Country | US
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Telephone | 910-907-8922
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Fax |
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Provider Business Mailing Address
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Address Line | 2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
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City | FORT BRAGG
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State | NC
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Zip | 28310-0001
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Country | US
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Telephone | 910-907-8922
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 30.026114
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 30.026114
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 30.026114
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License Number State | OH
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 30.026114
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License Number State | OH
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