Healthcare Provider Details

I. General information

NPI: 1285613695
Provider Name (Legal Business Name): MICHAEL ANTHONY KOCH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 DENTAL SQUADRON UNIT 3690
APO AE
09126
DE

IV. Provider business mailing address

PSC 9 BOX 1751
APO AE
09123
DE

V. Phone/Fax

Practice location:
  • Phone: 011496565958193
  • Fax:
Mailing address:
  • Phone: 011496561693844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number30-01-9288
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: