Provider Demographics
NPI:1972571909
Name:KOERTGE, THOMAS E (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:KOERTGE
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 1:521 N 11TH STREET
Mailing Address - Street 2:DEPARTMENT OF PERIODONTICS
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0566
Mailing Address - Country:US
Mailing Address - Phone:804-828-7952
Mailing Address - Fax:
Practice Address - Street 1:521 N 11TH STREET
Practice Address - Street 2:DENTAL FACULTY PRACTICE
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0566
Practice Address - Country:US
Practice Address - Phone:804-828-3368
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010061561223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics