Provider Demographics
NPI:1205318961
Name:KOTECKI, KRISTIN ELIZABETH (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:KOTECKI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:ELIZABETH
Other - Last Name:POTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2509 ELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-4421
Mailing Address - Country:US
Mailing Address - Phone:641-430-6008
Mailing Address - Fax:
Practice Address - Street 1:1939 N GREEN AVE
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-1733
Practice Address - Country:US
Practice Address - Phone:405-527-7388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK71191223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice