Provider Demographics
NPI:1285086009
Name:KOTCH, RUSSELL PERRY (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:PERRY
Last Name:KOTCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SW 129TH AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1761
Mailing Address - Country:US
Mailing Address - Phone:954-437-4443
Mailing Address - Fax:
Practice Address - Street 1:1 SW 129TH AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1761
Practice Address - Country:US
Practice Address - Phone:954-437-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21881122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist