Healthcare Provider Details

I. General information

NPI: 1982789269
Provider Name (Legal Business Name): DOUGLAS J. KOCH, D.D.S.,L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/22/2020
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: DR. DOUGLAS J KOCH
Title or Position: OWNER
Credential: D.D.S.
Phone: 301-663-0052