Healthcare Provider Details

I. General information

NPI: 1306844600
Provider Name (Legal Business Name): MARK LLEWELLYN KOCHEVAR D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 RIVERSIDE AVE
FORT COLLINS CO
80524-4348
US

IV. Provider business mailing address

1513 RIVERSIDE AVE
FORT COLLINS CO
80524-4348
US

V. Phone/Fax

Practice location:
  • Phone: 970-221-5090
  • Fax: 970-221-1879
Mailing address:
  • Phone: 970-221-5090
  • Fax: 970-221-1879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberCO6445
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier113973800
Identifier TypeMEDICAID
Identifier StateWY
Identifier Issuer
# 2
Identifier02064459
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: