Healthcare Provider Details

I. General information

NPI: 1174252746
Provider Name (Legal Business Name): JADE KOCH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/19/2022
Certification Date: 06/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 N MAIN ST
REDFIELD SD
57469-1208
US

IV. Provider business mailing address

1204 32ND AVE NE
ABERDEEN SD
57401-2631
US

V. Phone/Fax

Practice location:
  • Phone: 605-472-3700
  • Fax:
Mailing address:
  • Phone: 402-741-0545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD1363
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: