Provider Demographics
NPI:1154669190
Name:CHASE KOTULA DENTAL PARTNERSHIP
Entity Type:Organization
Organization Name:CHASE KOTULA DENTAL PARTNERSHIP
Other - Org Name:MARIN DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:KOTULA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-265-4115
Mailing Address - Street 1:4050 REDWOOD HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-5149
Mailing Address - Country:US
Mailing Address - Phone:415-499-7700
Mailing Address - Fax:
Practice Address - Street 1:4050 REDWOOD HWY
Practice Address - Street 2:SUITE A
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-5149
Practice Address - Country:US
Practice Address - Phone:415-499-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA593231223G0001X
CA373191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty