Provider Demographics
NPI:1497828545
Name:KOENITZER, ROBERT DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DAVID
Last Name:KOENITZER
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 1:101 LYNCH CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-8301
Mailing Address - Country:US
Mailing Address - Phone:707-762-6715
Mailing Address - Fax:707-763-1614
Practice Address - Street 1:101 LYNCH CREEK WAY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-8301
Practice Address - Country:US
Practice Address - Phone:707-762-6715
Practice Address - Fax:707-763-1614
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA346241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice