Provider Demographics
NPI:1205991858
Name:KOOTMAN, JEFFREY HOWARD (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:HOWARD
Last Name:KOOTMAN
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 1:702 E BELL RD
Mailing Address - Street 2:B103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022
Mailing Address - Country:US
Mailing Address - Phone:602-493-1140
Mailing Address - Fax:602-493-5328
Practice Address - Street 1:702 E BELL RD
Practice Address - Street 2:B103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022
Practice Address - Country:US
Practice Address - Phone:602-493-1140
Practice Address - Fax:602-493-5328
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ093229Medicaid
AZ093229Medicaid