Provider Demographics
NPI:1376887729
Name:TWIN RIVERS DENTAL
Entity Type:Organization
Organization Name:TWIN RIVERS DENTAL
Other - Org Name:J. KOTTENSTETTE DDS PC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTTENSTETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-545-5213
Mailing Address - Street 1:1320 FORTINO BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2081
Mailing Address - Country:US
Mailing Address - Phone:719-545-5213
Mailing Address - Fax:719-545-7076
Practice Address - Street 1:1320 FORTINO BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2081
Practice Address - Country:US
Practice Address - Phone:719-545-5213
Practice Address - Fax:719-545-7076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO91751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty