MEDICARE: DR. MATTHEW L KOOYMAN DDS

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	1223G0001X	General Practice Dentistry	D-3565	ID
2	122300000X	Dentist	D-3565	IL

General Provider Information

NPI Number	:	1699782854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW L KOOYMAN DDS

Provider Business Mailing Address
First Line	:	1500 W CAYUSE CREEK DR STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-4757
Country	:	US
Telephone Number	:	208-884-8858
Fax Number	:	208-884-8915

Provider Business Practice Location Address
First Line	:	1500 W CAYUSE CREEK DR STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-4757
Country	:	US
Telephone Number	:	508-884-8858
Fax Number	:	208-884-8915

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	11/09/2015

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