Provider Demographics
NPI:1568421782
Name:KOTOWSKI, MICHAEL JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:KOTOWSKI
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 1:515 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2366
Mailing Address - Country:US
Mailing Address - Phone:440-933-5428
Mailing Address - Fax:
Practice Address - Street 1:515 MOORE RD
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-2366
Practice Address - Country:US
Practice Address - Phone:440-933-5428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH151701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0315206Medicaid