Provider Demographics
NPI:1265085815
Name:KOMETANI, KURTIS KATSUMI (DMD)
Entity type:Individual
Prefix:DR
First Name:KURTIS
Middle Name:KATSUMI
Last Name:KOMETANI
Suffix:
Gender:
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:PSC 475 BOX 1
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350-1200
Mailing Address - Country:US
Mailing Address - Phone:315-243-7963
Mailing Address - Fax:
Practice Address - Street 1:PSC 475 BOX 1
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96350-1200
Practice Address - Country:US
Practice Address - Phone:315-243-7963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-2821122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist