Provider Demographics
NPI:1336177633
Name:KOEHLER, GLENN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:KOEHLER
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 1:192 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3581
Mailing Address - Country:US
Mailing Address - Phone:860-649-4655
Mailing Address - Fax:860-646-3281
Practice Address - Street 1:192 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-3581
Practice Address - Country:US
Practice Address - Phone:860-649-4655
Practice Address - Fax:860-646-3281
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6660208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics