Provider Demographics
NPI:1558360073
Name:KOCHEVAR, CASEY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:LEE
Last Name:KOCHEVAR
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 1:1446 HOVER STREET
Mailing Address - Street 2:SUITE #100
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501
Mailing Address - Country:US
Mailing Address - Phone:303-684-9777
Mailing Address - Fax:720-306-3517
Practice Address - Street 1:1446 HOVER STREET
Practice Address - Street 2:SUITE #100
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:303-684-9777
Practice Address - Fax:720-306-3517
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO84711223D0001X, 1223G0001X
CO8471CO1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78271045Medicaid
CO96800241Medicaid