Provider Demographics
NPI:1356946503
Name:KOCH, RENEE LYNN
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:LYNN
Last Name:KOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6645
Mailing Address - Country:US
Mailing Address - Phone:321-268-3300
Mailing Address - Fax:321-268-3552
Practice Address - Street 1:4400 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-6645
Practice Address - Country:US
Practice Address - Phone:321-268-3300
Practice Address - Fax:321-268-3552
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH12065124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist