Healthcare Provider Details

I. General information

NPI: 1821822172
Provider Name (Legal Business Name): BRIANNA NICOLE KOES DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 08/29/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ZACHARY AND ELIZABETH FISHER GREAT LAKES
DPO AA
60088
US

IV. Provider business mailing address

1328 LACI CT
INDIAN CREEK IL
60061-3279
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-2469
  • Fax:
Mailing address:
  • Phone: 623-687-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12057
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: