Provider Demographics
NPI:1942288865
Name:KOENKE, DOUGLAS WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:KOENKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42850 SCHOENHERR RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-2875
Mailing Address - Country:US
Mailing Address - Phone:586-566-0088
Mailing Address - Fax:586-566-0568
Practice Address - Street 1:42850 SCHOENHERR RD
Practice Address - Street 2:SUITE 5
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-2875
Practice Address - Country:US
Practice Address - Phone:586-566-0088
Practice Address - Fax:586-566-0568
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI130001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI13000OtherDENTAL LICENSE