Provider Demographics
NPI:1326028044
Name:KOONMEN, MARK EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:KOONMEN
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 1:1122 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3437
Mailing Address - Country:US
Mailing Address - Phone:810-732-0640
Mailing Address - Fax:810-732-2264
Practice Address - Street 1:1122 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3437
Practice Address - Country:US
Practice Address - Phone:810-732-0640
Practice Address - Fax:810-732-2264
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI137701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJ801645OtherBLUE CROSS AND BLUE SHIEL
MI1831730Medicaid