Healthcare Provider Details

I. General information

NPI: 1083767800
Provider Name (Legal Business Name): BRIAN D KOCH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S MONROE AVE
GREEN BAY WI
54301-4013
US

IV. Provider business mailing address

315 S MONROE AVE
GREEN BAY WI
54301-4013
US

V. Phone/Fax

Practice location:
  • Phone: 920-437-3376
  • Fax: 920-437-8474
Mailing address:
  • Phone: 920-437-3376
  • Fax: 920-437-8474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3863
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: