Provider Demographics
NPI:1104239615
Name:CULOTTA, KACIE MARIE (DMD)
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:MARIE
Last Name:CULOTTA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11671 JOLLYVILLE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4141
Mailing Address - Country:US
Mailing Address - Phone:512-345-9973
Mailing Address - Fax:
Practice Address - Street 1:11671 JOLLYVILLE RD STE 204
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4141
Practice Address - Country:US
Practice Address - Phone:512-345-9973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29962122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX29962OtherTEXAS STATE DENTAL LICENSE NUMBER