Healthcare Provider Details

I. General information

NPI: 1881449825
Provider Name (Legal Business Name): KYLE XAVIER KOCH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 04/23/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 W 10TH ST
GREELEY CO
80634-5367
US

IV. Provider business mailing address

5968 S KENTON WAY
ENGLEWOOD CO
80111-5726
US

V. Phone/Fax

Practice location:
  • Phone: 970-815-3910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00205931
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: