Provider Demographics
NPI:1396825998
Name:MARK E. KOONMEN, DDS, MS, PC
Entity Type:Organization
Organization Name:MARK E. KOONMEN, DDS, MS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KOONMEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-732-0640
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI137701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1831730Medicaid