Provider Demographics
NPI:1891827291
Name:KOTCH, HEYWOOD ROY (DMD)
Entity Type:Individual
Prefix:
First Name:HEYWOOD
Middle Name:ROY
Last Name:KOTCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 S 40TH ST
Mailing Address - Street 2:PENN DENTAL MEDICINE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-6030
Mailing Address - Country:US
Mailing Address - Phone:215-898-8946
Mailing Address - Fax:215-573-4090
Practice Address - Street 1:240 S 40TH ST
Practice Address - Street 2:PENN DENTAL MEDICINE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-6030
Practice Address - Country:US
Practice Address - Phone:215-898-8946
Practice Address - Fax:215-573-4090
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020796L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice