Provider Demographics
NPI:1679651194
Name:KOEN, JUSTIN DEXTER (DMD)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DEXTER
Last Name:KOEN
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 1:108 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUDA
Mailing Address - State:TX
Mailing Address - Zip Code:78610-3375
Mailing Address - Country:US
Mailing Address - Phone:512-295-9925
Mailing Address - Fax:512-295-5855
Practice Address - Street 1:108 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-3375
Practice Address - Country:US
Practice Address - Phone:512-295-9925
Practice Address - Fax:512-295-5855
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214291223G0001X
TX239611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100708OtherDELTA DENTAL
MAK10973OtherBC BS OF MA