Healthcare Provider Details

I. General information

NPI: 1639467236
Provider Name (Legal Business Name): JACOB E. KOCH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2011
Last Update Date: 07/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 TOWLER RD BLDG B
LAWRENCEVILLE GA
30046-4717
US

IV. Provider business mailing address

2401 CRANMORE CT
SNELLVILLE GA
30078-7733
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-9560
  • Fax:
Mailing address:
  • Phone: 678-977-8093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN014246
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: