1013136241 NPI number — DOUGLAS W. KOENKE, D.D.S.

Table of content: (NPI 1013136241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013136241 NPI number — DOUGLAS W. KOENKE, D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUGLAS W. KOENKE, D.D.S.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013136241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
42850 SCHOENHERR RD
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
STERLING HEIGHTS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48313-2875
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-566-0088
Provider Business Mailing Address Fax Number:
586-566-0568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42850 SCHOENHERR RD
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
STERLING HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48313-2875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-566-0088
Provider Business Practice Location Address Fax Number:
586-566-0568
Provider Enumeration Date:
04/25/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KOENKE
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
586-566-0088

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  13000 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)