Provider Demographics
NPI:1558355529
Name:KOTERWAS, GARY EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:EDWARD
Last Name:KOTERWAS
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 1:19414 LEITERSBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-7601
Mailing Address - Country:US
Mailing Address - Phone:301-791-1700
Mailing Address - Fax:301-791-9257
Practice Address - Street 1:19414 LEITERSBURG PIKE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-7601
Practice Address - Country:US
Practice Address - Phone:301-791-1700
Practice Address - Fax:301-791-9257
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD113751223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U80909Medicare UPIN
MD06NNMedicare ID - Type Unspecified