Provider Demographics
NPI:1376948372
Name:KOCH, MARK ROSS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROSS
Last Name:KOCH
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 1:521 EDGEWATER RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-5633
Mailing Address - Country:US
Mailing Address - Phone:410-255-7471
Mailing Address - Fax:
Practice Address - Street 1:521 EDGEWATER RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-5633
Practice Address - Country:US
Practice Address - Phone:410-255-7471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-03
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5985122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist