1730538661 NPI number — GIANNA PAOLA KOKER SURGEON DENTIST

Table of content: GIANNA PAOLA KOKER SURGEON DENTIST (NPI 1730538661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730538661 NPI number — GIANNA PAOLA KOKER SURGEON DENTIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOKER
Provider First Name:
GIANNA
Provider Middle Name:
PAOLA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SURGEON DENTIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOKER
Provider Other First Name:
GIANNA
Provider Other Middle Name:
PAOLA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730538661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
973 SKYLINE DR SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55902-1220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-996-5851
Provider Business Mailing Address Fax Number:
507-424-1042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4310 MENARD DR STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55811-1564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-279-9985
Provider Business Practice Location Address Fax Number:
218-279-9987
Provider Enumeration Date:
06/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  LGL14 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 14279 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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