Provider Demographics
NPI:1598961526
Name:KOUCH, GREGORY ALLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALLEN
Last Name:KOUCH
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 1:752 BROOKSHIRE DR
Mailing Address - Street 2:SUITE D. P.O. BOX 1388
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-4510
Mailing Address - Country:US
Mailing Address - Phone:724-981-5460
Mailing Address - Fax:724-981-3297
Practice Address - Street 1:752 BROOKSHIRE DR
Practice Address - Street 2:SUITE D.
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-4510
Practice Address - Country:US
Practice Address - Phone:724-981-5460
Practice Address - Fax:724-981-3297
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-027044-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice