Provider Demographics
NPI:1073095501
Name:KOEPL, CARMEN LEE
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:LEE
Last Name:KOEPL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:
Practice Address - Street 1:803 S MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2695
Practice Address - Country:US
Practice Address - Phone:208-848-8300
Practice Address - Fax:208-882-5587
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60888742124Q00000X
IDDH-3679124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist