MEDICARE: DR. GEOFFREY ROBERT KOPECKY 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	30831	CA

General Provider Information

NPI Number	:	1083796692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEOFFREY ROBERT KOPECKY DDS

Provider Business Mailing Address
First Line	:	PO BOX 675667
Second Line	:
City	:	RANCHO SANTA FE
State	:	CA
Zip	:	92067-5667
Country	:	US
Telephone Number	:	858-259-1669
Fax Number	:

Provider Business Practice Location Address
First Line	:	3820 CONVOY ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-3722
Country	:	US
Telephone Number	:	858-569-1100
Fax Number	:

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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