Healthcare Provider Details

I. General information

NPI: 1043441108
Provider Name (Legal Business Name): JEREMY J KOPPENHAVER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 W 6TH STREET BLDG 440
FORT STEWART GA
31314
US

IV. Provider business mailing address

351 W 6TH STREET BLDG 440
FORT STEWART GA
31314
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-7006
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS38003
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS038003
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: