Provider Demographics
NPI:1760169122
Name:KOCH, RYAN MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:KOCH
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:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:MC ELHATTAN
Mailing Address - State:PA
Mailing Address - Zip Code:17748-0523
Mailing Address - Country:US
Mailing Address - Phone:570-651-3559
Mailing Address - Fax:
Practice Address - Street 1:42 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MUNCY
Practice Address - State:PA
Practice Address - Zip Code:17756-1307
Practice Address - Country:US
Practice Address - Phone:570-546-3419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0441921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice