MEDICARE: DR. MITCHELL W KOTZEN D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	13261	MA

General Provider Information

NPI Number	:	1548280472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITCHELL W KOTZEN D.M.D.

Provider Business Mailing Address
First Line	:	200 N MAIN ST
Second Line	:	1104
City	:	EAST LONGMEADOW
State	:	MA
Zip	:	01028-2392
Country	:	US
Telephone Number	:	413-525-6123
Fax Number	:	413-525-8999

Provider Business Practice Location Address
First Line	:	200 N MAIN ST
Second Line	:	1104
City	:	EAST LONGMEADOW
State	:	MA
Zip	:	01028-2392
Country	:	US
Telephone Number	:	413-525-6123
Fax Number	:	413-525-8999

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	07/08/2007

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