Individual
DR. IVAN SERGEYEVICH KOUTSOPATRIY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2817 ROCK MERRITT AVE, WOMACK ARMY MEDICAL CENTER, FORT BRAGG, NC 28310-0001
(910) 907-8922
Mailing address
2817 ROCK MERRITT AVE, WOMACK ARMY MEDICAL CENTER, FORT BRAGG, NC 28310-0001
(910) 907-8922
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
30.026114
OH
1223G0001X
General Practice Dentistry
30.026114
OH
1223P0700X
Prosthodontics
Primary
30.026114
OH
390200000X
Student in an Organized Health Care Education/Training Program
30.026114
OH
Other
Enumeration date
05/18/2020
Last updated
03/03/2026
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