Provider Demographics
NPI:1609007475
Name:KOTIS, AMANDA BROWN (DMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BROWN
Last Name:KOTIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 DAVIE AVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-3511
Mailing Address - Country:US
Mailing Address - Phone:704-873-4271
Mailing Address - Fax:
Practice Address - Street 1:1207 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3511
Practice Address - Country:US
Practice Address - Phone:704-873-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC91941223G0001X
NC1507461223G0001X
NY0551081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice