Healthcare Provider Details

I. General information

NPI: 1710083324
Provider Name (Legal Business Name): JOHN CONSTANTINE KOIS DMD, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5615 VALLEY AVE E
TACOMA WA
98424-2060
US

IV. Provider business mailing address

5615 VALLEY AVE E
TACOMA WA
98424-2060
US

V. Phone/Fax

Practice location:
  • Phone: 253-922-6056
  • Fax: 253-922-3517
Mailing address:
  • Phone: 253-922-6056
  • Fax: 253-922-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDE00005799
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: