Provider Demographics
NPI:1821208646
Name:KOYOMJI, RICHARD C
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:KOYOMJI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8218 WISCONSIN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-3107
Mailing Address - Country:US
Mailing Address - Phone:301-654-1111
Mailing Address - Fax:301-654-2227
Practice Address - Street 1:8218 WISCONSIN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-3107
Practice Address - Country:US
Practice Address - Phone:301-654-1111
Practice Address - Fax:301-654-2227
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12381122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist