Basic Information
| Provider Information | |||||||||
| NPI: | 1780744136 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOTTKE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | BOYD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4107 PITT ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558041959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632185524 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187286445 | ||||||||
| FaxNumber: | 2187247003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 05/25/2011 | ||||||||
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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 | 1223G0001X | D11988 | MN | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1628988 | 01 | UNITED CONCORDIA | OTHER | 822028000 | 05 | MN | MEDICAID |