Healthcare Provider Details

I. General information

NPI: 1992258768
Provider Name (Legal Business Name): JAMES MICHAEL KOON JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 04/10/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 402 UNIT 33301
APO AE
09180
US

IV. Provider business mailing address

CMR 402 UNIT 33301
APO AE
09180
US

V. Phone/Fax

Practice location:
  • Phone: 314-636-9210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN015169
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: