Provider Demographics
NPI:1578633665
Name:TED B KOESTER DMD PC
Entity Type:Organization
Organization Name:TED B KOESTER DMD PC
Other - Org Name:CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:MR
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:KOESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-342-4494
Mailing Address - Street 1:111 SOUTH FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401
Mailing Address - Country:US
Mailing Address - Phone:217-342-4494
Mailing Address - Fax:217-347-5344
Practice Address - Street 1:111 SOUTH FIRST STREET
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401
Practice Address - Country:US
Practice Address - Phone:217-342-4494
Practice Address - Fax:217-347-5344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty