Provider Demographics
NPI:1336478882
Name:KOTUBY, PAUL M JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:KOTUBY
Suffix:JR
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 1:15 GOODING AVENUE, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-2600
Mailing Address - Country:US
Mailing Address - Phone:401-253-3781
Mailing Address - Fax:401-253-9324
Practice Address - Street 1:15 GOODING AVENUE, SUITE 1
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-2600
Practice Address - Country:US
Practice Address - Phone:401-253-3781
Practice Address - Fax:401-253-9324
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN01874122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIBD-24695Medicaid