Provider Demographics
NPI:1043406283
Name:KOTROB, MOUTAZ (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOUTAZ
Middle Name:
Last Name:KOTROB
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 EL CAMINO REAL STE 5
Mailing Address - Street 2:# B -304
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1133 EL CAMINO REAL STE 5
Practice Address - Street 2:# B -304
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-3288
Practice Address - Country:US
Practice Address - Phone:650-244-9928
Practice Address - Fax:650-244-9284
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA559811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice