Provider Demographics
NPI:1144423427
Name:KOTLYARENKO, INNA (DDS)
Entity Type:Individual
Prefix:DR
First Name:INNA
Middle Name:
Last Name:KOTLYARENKO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10425 W NORTH AVE
Mailing Address - Street 2:SUITE 335
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-476-3909
Mailing Address - Fax:414-476-3909
Practice Address - Street 1:10425 W NORTH AVE
Practice Address - Street 2:SUITE 335
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-476-3909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33468300Medicaid