Healthcare Provider Details

I. General information

NPI: 1609915677
Provider Name (Legal Business Name): MENAKSHY KOUL D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 HAMPTON CTR STE A
MORGANTOWN WV
26505-1704
US

IV. Provider business mailing address

2000 HAMPTON CTR STE A
MORGANTOWN WV
26505-1704
US

V. Phone/Fax

Practice location:
  • Phone: 304-599-9558
  • Fax: 304-599-9559
Mailing address:
  • Phone: 304-599-9558
  • Fax: 304-599-9559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3717
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: