Provider Demographics
NPI:1083796486
Name:KOTSOPEY, OMELAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:OMELAN
Middle Name:
Last Name:KOTSOPEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08611-1410
Mailing Address - Country:US
Mailing Address - Phone:609-393-6891
Mailing Address - Fax:609-393-1128
Practice Address - Street 1:1100 S BROAD ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08611-1410
Practice Address - Country:US
Practice Address - Phone:609-393-6891
Practice Address - Fax:609-393-1128
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01317800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist