Healthcare Provider Details

I. General information

NPI: 1851892434
Provider Name (Legal Business Name): ANNE LAUREN KOCH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 LEWIS BAY BLVD SUITE 4
WEST YARMOUTH MA
02673
US

IV. Provider business mailing address

PO BOX 778
WEST YARMOUTH MA
02673
US

V. Phone/Fax

Practice location:
  • Phone: 631-219-9845
  • Fax:
Mailing address:
  • Phone: 631-219-9845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN13735
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: