Provider Demographics
NPI:1376539056
Name:KOEHL, GARY LIONEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LIONEL
Last Name:KOEHL
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 1:1015 SHOOK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2508
Mailing Address - Country:US
Mailing Address - Phone:210-826-2373
Mailing Address - Fax:210-826-2374
Practice Address - Street 1:1015 SHOOK AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2508
Practice Address - Country:US
Practice Address - Phone:210-826-2373
Practice Address - Fax:210-826-2374
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD10371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
527724OtherUNITED CONCORDIA
TXBK04OtherBCBS
T14237Medicare UPIN
D10371Medicare ID - Type Unspecified