Healthcare Provider Details

I. General information

NPI: 1811072291
Provider Name (Legal Business Name): DOUGLAS JOHN KOCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 THOMAS JOHNSON CT SUITE A
FREDERICK MD
21702-4331
US

IV. Provider business mailing address

9354 CABBAGE RUN RD
FREDERICK MD
21701-2214
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-0052
  • Fax:
Mailing address:
  • Phone: 301-845-7759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number8687
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: