Healthcare Provider Details

I. General information

NPI: 1336570837
Provider Name (Legal Business Name): KOCH & CROSSLEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 RUSSELL PKWY
WARNER ROBINS GA
31088-5582
US

IV. Provider business mailing address

1299 RUSSELL PKWY
WARNER ROBINS GA
31088-5582
US

V. Phone/Fax

Practice location:
  • Phone: 478-923-6449
  • Fax:
Mailing address:
  • Phone: 478-923-6449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN013676
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN010803
License Number StateGA

VIII. Authorized Official

Name: LAURA KOCH
Title or Position: DENTIST
Credential:
Phone: 478-923-6449