Provider Demographics
NPI:1376964429
Name:KOTELLI, MIGENA (DDS)
Entity Type:Individual
Prefix:
First Name:MIGENA
Middle Name:
Last Name:KOTELLI
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 1:9205 RIDGE BLVD
Mailing Address - Street 2:AP 4A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-6244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9205 RIDGE BLVD
Practice Address - Street 2:AP 4A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-6244
Practice Address - Country:US
Practice Address - Phone:857-453-0987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50 0570931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice