Healthcare Provider Details

I. General information

NPI: 1215496559
Provider Name (Legal Business Name): AJAY KOYA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2019
Last Update Date: 03/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

IV. Provider business mailing address

670 W WAYMAN ST APT 2101
CHICAGO IL
60661-1703
US

V. Phone/Fax

Practice location:
  • Phone: 570-214-2128
  • Fax:
Mailing address:
  • Phone: 847-533-4181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: