Provider Demographics
NPI:1467059071
Name:KOONTZ, JEREMY PARCO (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:PARCO
Last Name:KOONTZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2380
Mailing Address - Country:US
Mailing Address - Phone:360-825-2191
Mailing Address - Fax:
Practice Address - Street 1:2617 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2380
Practice Address - Country:US
Practice Address - Phone:360-825-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE611006941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice