Healthcare Provider Details

I. General information

NPI: 1326028044
Provider Name (Legal Business Name): MARK EDWARD KOONMEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 S LINDEN RD
FLINT MI
48532-3437
US

IV. Provider business mailing address

1122 S LINDEN RD
FLINT MI
48532-3437
US

V. Phone/Fax

Practice location:
  • Phone: 810-732-0640
  • Fax: 810-732-2264
Mailing address:
  • Phone: 810-732-0640
  • Fax: 810-732-2264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number13770
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: