Provider Demographics
NPI:1639467236
Name:KOCH, JACOB E (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:E
Last Name:KOCH
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 1:2401 CRANMORE CT
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-7733
Mailing Address - Country:US
Mailing Address - Phone:678-977-8093
Mailing Address - Fax:
Practice Address - Street 1:55 TOWLER RD BLDG B
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4717
Practice Address - Country:US
Practice Address - Phone:770-962-9560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-16
Last Update Date:2011-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0142461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics