Provider Demographics
NPI:1316961329
Name:POTOCSKY, KEVIN JOEL (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOEL
Last Name:POTOCSKY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17234 GODDARD RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-4100
Mailing Address - Country:US
Mailing Address - Phone:313-381-1633
Mailing Address - Fax:313-381-2504
Practice Address - Street 1:17234 GODDARD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-4100
Practice Address - Country:US
Practice Address - Phone:313-381-1633
Practice Address - Fax:313-381-2504
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18258122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist