Healthcare Provider Details

I. General information

NPI: 1518058189
Provider Name (Legal Business Name): GLENN W KOECHLING DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 NORTH 18TH STREET
KENILWORTH NJ
07033
US

IV. Provider business mailing address

17 NORTH 18TH STREET
KENILWORTH NJ
07033
US

V. Phone/Fax

Practice location:
  • Phone: 908-272-4170
  • Fax: 908-272-1420
Mailing address:
  • Phone: 908-272-4170
  • Fax: 908-272-1420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10578
License Number StateNJ

VIII. Authorized Official

Name: GLENN W KOECHLING
Title or Position: PRESIDENT
Credential: DDS
Phone: 908-272-4170