Provider Demographics
NPI:1811072291
Name:KOCH, DOUGLAS JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JOHN
Last Name:KOCH
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 1:9354 CABBAGE RUN RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-2214
Mailing Address - Country:US
Mailing Address - Phone:301-845-7759
Mailing Address - Fax:
Practice Address - Street 1:85 THOMAS JOHNSON CT
Practice Address - Street 2:SUITE A
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4331
Practice Address - Country:US
Practice Address - Phone:301-663-0052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD86871223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics