Healthcare Provider Details

I. General information

NPI: 1477558971
Provider Name (Legal Business Name): GUNTHER G. KOCH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3487 CENTER RD
BRUNSWICK OH
44212-3624
US

IV. Provider business mailing address

3487 CENTER RD
BRUNSWICK OH
44212-3624
US

V. Phone/Fax

Practice location:
  • Phone: 330-273-1600
  • Fax:
Mailing address:
  • Phone: 330-273-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30-01-6437
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: