Provider Demographics
NPI:1730619735
Name:KOCH, KELLY (DMD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NASSAU ST APT 807
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56 NEW DRIFTWAY
Practice Address - Street 2:
Practice Address - City:SCITUATE
Practice Address - State:MA
Practice Address - Zip Code:02066-4533
Practice Address - Country:US
Practice Address - Phone:781-545-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18576171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice