Provider Demographics
NPI:1114148475
Name:KOUKOL, EMMA J (DDS)
Entity Type:Individual
Prefix:DR
First Name:EMMA
Middle Name:J
Last Name:KOUKOL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:411 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3739
Mailing Address - Country:US
Mailing Address - Phone:978-263-1154
Mailing Address - Fax:978-263-1155
Practice Address - Street 1:411 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3739
Practice Address - Country:US
Practice Address - Phone:978-263-1154
Practice Address - Fax:978-263-1155
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA139591223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics