Provider Demographics
NPI:1316019540
Name:CONCEPT 3000 DENTAL INC
Entity Type:Organization
Organization Name:CONCEPT 3000 DENTAL INC
Other - Org Name:C RANDALL KOEPKE DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:KOEPKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-882-1300
Mailing Address - Street 1:6000 RENAISSANCE PLACE
Mailing Address - Street 2:SUITE B
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4715
Mailing Address - Country:US
Mailing Address - Phone:419-882-1300
Mailing Address - Fax:
Practice Address - Street 1:6000 RENAISSANCE PLACE
Practice Address - Street 2:SUITE B
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4715
Practice Address - Country:US
Practice Address - Phone:419-882-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14687122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty