Provider Demographics
NPI:1508494469
Name:KOSCHUCK, SHELBY QUINN COULTER (DDS)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:QUINN COULTER
Last Name:KOSCHUCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:846 KENWOOD BLVD.
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ONT
Mailing Address - Zip Code:N9J3C5
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-327-3041
Practice Address - Fax:708-327-3489
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0180021461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice