Provider Demographics
NPI:1609958826
Name:KOETT, JOHN LEELAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEELAND
Last Name:KOETT
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 1:681 ENCINITAS BLVD STE 317
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-3762
Mailing Address - Country:US
Mailing Address - Phone:760-753-6496
Mailing Address - Fax:760-753-4576
Practice Address - Street 1:681 ENCINITAS BLVD STE 317
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-3762
Practice Address - Country:US
Practice Address - Phone:760-753-6496
Practice Address - Fax:760-753-4576
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA516051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice