Provider Demographics
NPI:1841357522
Name:KOLLER, MARK JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:KOLLER
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 1:1606 W CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-1516
Mailing Address - Country:US
Mailing Address - Phone:847-255-8439
Mailing Address - Fax:847-255-7664
Practice Address - Street 1:1606 W CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1516
Practice Address - Country:US
Practice Address - Phone:847-255-8439
Practice Address - Fax:847-255-8770
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist