MEDICARE: DR. MARK RICHARD KOENEN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	36780	CA

General Provider Information

NPI Number	:	1023111952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK RICHARD KOENEN DDS

Provider Business Mailing Address
First Line	:	520 LA GONDA WAY
Second Line	:	SUITE 204
City	:	DANVILLE
State	:	CA
Zip	:	94526-1741
Country	:	US
Telephone Number	:	925-837-6318
Fax Number	:	925-837-4992

Provider Business Practice Location Address
First Line	:	520 LA GONDA WAY
Second Line	:	# 204
City	:	DANVILLE
State	:	CA
Zip	:	94526-1741
Country	:	US
Telephone Number	:	925-837-6318
Fax Number	:	925-837-4992

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	11/07/2012

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