Provider Demographics
NPI:1023472230
Name:KOCH, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 SAINT HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-2138
Mailing Address - Country:US
Mailing Address - Phone:302-632-3116
Mailing Address - Fax:
Practice Address - Street 1:633 GREENWAY RD SE
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3713
Practice Address - Country:US
Practice Address - Phone:410-761-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC88141223G0001X
MD176621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice