Provider Demographics
NPI:1649269705
Name:KOTSAY, KRIS (DENTIST)
Entity type:Individual
Prefix:
First Name:KRIS
Middle Name:
Last Name:KOTSAY
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 BLACK ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-1200
Mailing Address - Country:US
Mailing Address - Phone:203-579-5223
Mailing Address - Fax:203-332-0376
Practice Address - Street 1:64 BLACK ROCK AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1200
Practice Address - Country:US
Practice Address - Phone:203-579-5223
Practice Address - Fax:203-332-0376
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009330122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT009330OtherSTATE LICENSE