Provider Demographics
NPI:1649257098
Name:KOCH, KIMBERLY A (DDS)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:KOCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 S MADISON ST
Mailing Address - Street 2:PO BOX 1676
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-5756
Mailing Address - Country:US
Mailing Address - Phone:765-281-4257
Mailing Address - Fax:765-213-2769
Practice Address - Street 1:3715 S MADISON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47302-5756
Practice Address - Country:US
Practice Address - Phone:765-281-4257
Practice Address - Fax:765-213-2769
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010451A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200386460Medicaid
IN200386460Medicaid
IN199440BMedicare ID - Type Unspecified