Provider Demographics
NPI:1659013456
Name:KOENTJORO DENTISTRY DODGE LLC
Entity Type:Organization
Organization Name:KOENTJORO DENTISTRY DODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:KOENTJORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-346-6800
Mailing Address - Street 1:PO BOX 70887
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44190-0887
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7059 DODGE ST STE 102
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68132-2703
Practice Address - Country:US
Practice Address - Phone:402-346-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-12
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty