Provider Demographics
NPI:1750468856
Name:KOUP, MARK ANDREW (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDREW
Last Name:KOUP
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 1:325 CENTRAL AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-3219
Mailing Address - Country:US
Mailing Address - Phone:610-644-0408
Mailing Address - Fax:610-647-1024
Practice Address - Street 1:325 CENTRAL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3219
Practice Address - Country:US
Practice Address - Phone:610-644-0408
Practice Address - Fax:610-647-1024
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0364841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice