Basic Information
| Provider Information | |||||||||
| NPI: | 1649269705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOTSAY | ||||||||
| FirstName: | KRIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DENTIST | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 64 BLACK ROCK AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066051200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035795223 | ||||||||
| FaxNumber: | 2033320376 | ||||||||
| Practice Location | |||||||||
| Address1: | 64 BLACK ROCK AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066051200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035795223 | ||||||||
| FaxNumber: | 2033320376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 009330 | CT | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 009330 | 01 | CT | STATE LICENSE | OTHER |