MEDICARE: RENEE LYNN KOCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	DH12065	FL

General Provider Information

NPI Number	:	1356946503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE LYNN KOCH

Provider Business Mailing Address
First Line	:	4400 S WASHINGTON AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-6645
Country	:	US
Telephone Number	:	321-268-3300
Fax Number	:	321-268-3552

Provider Business Practice Location Address
First Line	:	4400 S WASHINGTON AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-6645
Country	:	US
Telephone Number	:	321-268-3300
Fax Number	:	321-268-3552

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2020
Last Update Date	:	03/08/2026

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