Provider Demographics
NPI:1508927849
Name:KOCH, CONRAD (DMD)
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:
Last Name:KOCH
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 1:300 WEYMAN RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-1520
Mailing Address - Country:US
Mailing Address - Phone:412-882-1320
Mailing Address - Fax:412-882-0167
Practice Address - Street 1:300 WEYMAN RD
Practice Address - Street 2:SUITE 260
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15236-1520
Practice Address - Country:US
Practice Address - Phone:412-882-1320
Practice Address - Fax:412-882-0167
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018185L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist