Provider Demographics
NPI:1023111952
Name:KOENEN, MARK RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:KOENEN
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 1:520 LA GONDA WAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-1741
Mailing Address - Country:US
Mailing Address - Phone:925-837-6318
Mailing Address - Fax:925-837-4992
Practice Address - Street 1:520 LA GONDA WAY
Practice Address - Street 2:# 204
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-1741
Practice Address - Country:US
Practice Address - Phone:925-837-6318
Practice Address - Fax:925-837-4992
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA367801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice