Provider Demographics
NPI:1538381330
Name:KOOISTRA, CHARLOTTE MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:MARIE
Last Name:KOOISTRA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24-40 27 ST
Mailing Address - Street 2:#3A
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2312
Mailing Address - Country:US
Mailing Address - Phone:718-728-6657
Mailing Address - Fax:
Practice Address - Street 1:424 LEONARD ST
Practice Address - Street 2:JHS 126
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222
Practice Address - Country:US
Practice Address - Phone:718-782-2527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038912122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist