Healthcare Provider Details

I. General information

NPI: 1124766423
Provider Name (Legal Business Name): MICHAEL DAVID KOERNER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 05/13/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22201 MOROSS PROFESSIONAL BUILDING II, SUITE 155
DETROIT MI
48236
US

IV. Provider business mailing address

22201 MOROSS PROFESSIONAL BUILDING II, SUITE 155
DETROIT MI
48236
US

V. Phone/Fax

Practice location:
  • Phone: 313-499-4775
  • Fax: 313-499-4952
Mailing address:
  • Phone: 313-499-4775
  • Fax: 313-499-4952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS043703
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: