Provider Demographics
NPI:1306844600
Name:KOCHEVAR, MARK LLEWELLYN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LLEWELLYN
Last Name:KOCHEVAR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4348
Mailing Address - Country:US
Mailing Address - Phone:970-221-5090
Mailing Address - Fax:970-221-1879
Practice Address - Street 1:1513 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4348
Practice Address - Country:US
Practice Address - Phone:970-221-5090
Practice Address - Fax:970-221-1879
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO64451223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY113973800Medicaid
CO02064459Medicaid