Provider Demographics
NPI:1053085365
Name:BERMUDEZ-KOCH, JB MCGREGOR (DMD DE61197009)
Entity Type:Individual
Prefix:DR
First Name:JB
Middle Name:MCGREGOR
Last Name:BERMUDEZ-KOCH
Suffix:
Gender:M
Credentials:DMD DE61197009
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 E HANDY RD
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005-9225
Mailing Address - Country:US
Mailing Address - Phone:208-615-0533
Mailing Address - Fax:
Practice Address - Street 1:15810 E INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1864
Practice Address - Country:US
Practice Address - Phone:509-795-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61197009122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist