Provider Demographics
NPI:1780230896
Name:KUTROLLI, JOHANA (DDS)
Entity Type:Individual
Prefix:
First Name:JOHANA
Middle Name:
Last Name:KUTROLLI
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 1:1415 GOVERNORS SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-3049
Mailing Address - Country:US
Mailing Address - Phone:718-350-6774
Mailing Address - Fax:
Practice Address - Street 1:1415 GOVERNORS SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3049
Practice Address - Country:US
Practice Address - Phone:850-688-9095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24526122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist