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General NPI Number Information
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NPI Number | 1538653704
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Entity Type | Individual
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Provider Name | ANDREW KOKANOUTRANON DMD
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Gender | Male
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Dates
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Enumeration Date | 06/20/2018
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Last Update Date | 03/18/2022
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Provider Practice Location Address
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Address Line | 7448 W GLENDALE AVE STE 126
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City | GLENDALE
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State | AZ
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Zip | 85303-2546
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Country | US
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Telephone | 623-930-0060
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Fax |
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Provider Business Mailing Address
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Address Line | 22015 N 28TH PL
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City | PHOENIX
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State | AZ
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Zip | 85050-8222
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Country | US
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Telephone | 949-232-7309
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | D010057
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License Number State | AZ
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