Provider Demographics
NPI:1679823058
Name:MICHAEL R. COTTAM MS DMD PLLC
Entity Type:Organization
Organization Name:MICHAEL R. COTTAM MS DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:COTTAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-261-3178
Mailing Address - Street 1:4775 W DAYBREAK PKWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5968
Mailing Address - Country:US
Mailing Address - Phone:801-261-3178
Mailing Address - Fax:801-268-1930
Practice Address - Street 1:4775 W DAYBREAK PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5968
Practice Address - Country:US
Practice Address - Phone:801-261-3178
Practice Address - Fax:801-268-1930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
8296939-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty