Provider Demographics
NPI:1083796692
Name:KOPECKY, GEOFFREY ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:ROBERT
Last Name:KOPECKY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 675667
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA FE
Mailing Address - State:CA
Mailing Address - Zip Code:92067-5667
Mailing Address - Country:US
Mailing Address - Phone:858-259-1669
Mailing Address - Fax:
Practice Address - Street 1:3820 CONVOY ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3722
Practice Address - Country:US
Practice Address - Phone:858-569-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA308311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics