Provider Demographics
NPI:1659682888
Name:KOTULA, JACQUELINE M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:M
Last Name:KOTULA
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 1:4050 REDWOOD HWY STE A
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-5149
Mailing Address - Country:US
Mailing Address - Phone:415-499-7700
Mailing Address - Fax:
Practice Address - Street 1:1648 UNION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-4508
Practice Address - Country:US
Practice Address - Phone:415-474-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59323122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist