Provider Demographics
NPI:1184834442
Name:KOTSUBO, JEFFREY MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:KOTSUBO
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 1:1304 15TH ST
Mailing Address - Street 2:SUITE #318
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1809
Mailing Address - Country:US
Mailing Address - Phone:310-458-6677
Mailing Address - Fax:
Practice Address - Street 1:1304 15TH ST
Practice Address - Street 2:SUITE #318
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1809
Practice Address - Country:US
Practice Address - Phone:310-458-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA384391223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics