Provider Demographics
NPI:1770599144
Name:KOONING, JAN ANDREW (DMD PC)
Entity type:Individual
Prefix:MR
First Name:JAN
Middle Name:ANDREW
Last Name:KOONING
Suffix:
Gender:M
Credentials:DMD PC
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Mailing Address - Street 1:3549 N LOMBARD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-5901
Mailing Address - Country:US
Mailing Address - Phone:503-289-9621
Mailing Address - Fax:503-289-2930
Practice Address - Street 1:3549 N LOMBARD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-5901
Practice Address - Country:US
Practice Address - Phone:503-289-9621
Practice Address - Fax:503-289-2930
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORD60811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery