MEDICARE: DONALD A KOONTZ D.D.S.

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	122300000X	Dentist	6865	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6865	OTHER	WA	ST. DENTAL LICENSE #

General Provider Information

NPI Number	:	1548356918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD A KOONTZ D.D.S.

Provider Business Mailing Address
First Line	:	16518 39TH AVE NE
Second Line	:
City	:	LAKE FOREST PARK
State	:	WA
Zip	:	98155-5602
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12806 3RD AVE SE
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98208-6455
Country	:	US
Telephone Number	:	425-338-0666
Fax Number	:	425-337-6570

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	07/08/2007

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