Healthcare Provider Details

I. General information

NPI: 1215227210
Provider Name (Legal Business Name): MICHAEL KENNETH KOCEJA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 SE 136TH AVE 103
VANCOUVER WA
98684-6907
US

IV. Provider business mailing address

217 SE 136TH AVE 103
VANCOUVER WA
98684-6907
US

V. Phone/Fax

Practice location:
  • Phone: 360-953-8135
  • Fax: 360-953-8124
Mailing address:
  • Phone: 360-953-8135
  • Fax: 360-953-8124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00009967
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: