MEDICARE: JO KOONTZ CRONLY D.D.S.

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	1223P0221X	Pediatric Dentistry	0401413637	VA

General Provider Information

NPI Number	:	1396007340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JO KOONTZ CRONLY D.D.S.

Provider Business Mailing Address
First Line	:	2400 COLONY CROSSING PL
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-4281
Country	:	US
Telephone Number	:	804-639-6445
Fax Number	:	804-639-6400

Provider Business Practice Location Address
First Line	:	2400 COLONY CROSSING PL
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-4281
Country	:	US
Telephone Number	:	804-639-6445
Fax Number	:	804-639-6400

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

Provider Enumeration Date	:	06/14/2012
Last Update Date	:	01/17/2017

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