Provider Demographics
NPI:1396880480
Name:MARVIN C KOONCE DDS PC
Entity type:Organization
Organization Name:MARVIN C KOONCE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOONCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-684-2445
Mailing Address - Street 1:PO BOX 741
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37162-0741
Mailing Address - Country:US
Mailing Address - Phone:931-684-2445
Mailing Address - Fax:931-684-6201
Practice Address - Street 1:603 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3210
Practice Address - Country:US
Practice Address - Phone:931-684-2445
Practice Address - Fax:931-684-6201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS23221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty