Provider Demographics
NPI:1942457783
Name:KOONSE, JENNIFER ANN (DMD)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANN
Last Name:KOONSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9171 CENTRAL AVE
Mailing Address - Street 2:SUITE L9
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-3837
Mailing Address - Country:US
Mailing Address - Phone:301-336-7535
Mailing Address - Fax:301-336-3781
Practice Address - Street 1:9171 CENTRAL AVE
Practice Address - Street 2:SUITE L9
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-3837
Practice Address - Country:US
Practice Address - Phone:301-336-7535
Practice Address - Fax:301-336-3781
Is Sole Proprietor?:No
Enumeration Date:2008-08-23
Last Update Date:2008-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD138501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice