Provider Demographics
NPI:1649459264
Name:KOCH, JASON MANTLE (DMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MANTLE
Last Name:KOCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CAMBRON DR
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-2245
Mailing Address - Country:US
Mailing Address - Phone:502-460-2976
Mailing Address - Fax:
Practice Address - Street 1:95 RAYWICK RD
Practice Address - Street 2:
Practice Address - City:ST MARY
Practice Address - State:KY
Practice Address - Zip Code:40063-8800
Practice Address - Country:US
Practice Address - Phone:270-699-4074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7252122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist