Healthcare Provider Details

I. General information

NPI: 1104881663
Provider Name (Legal Business Name): TOMMY J KOEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 INDIAN LAKE BLVD SUITE 202
HENDERSONVILLE TN
37045
US

IV. Provider business mailing address

131 INDIAN LAKE BLVD SUITE 202
HENDERSONVILLE TN
37045
US

V. Phone/Fax

Practice location:
  • Phone: 615-824-5636
  • Fax: 615-824-5707
Mailing address:
  • Phone: 615-824-5636
  • Fax: 615-824-5707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4113
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: