Provider Demographics
NPI:1558474304
Name:KOEHLER, VICTOR A (DMD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:A
Last Name:KOEHLER
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 1:3238 KRISAM CREEK DR.
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052
Mailing Address - Country:US
Mailing Address - Phone:770-466-0474
Mailing Address - Fax:770-482-1396
Practice Address - Street 1:3238 KRISAM CREEK DR.
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052
Practice Address - Country:US
Practice Address - Phone:770-466-0474
Practice Address - Fax:770-482-1396
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice