Provider Demographics
NPI:1780101659
Name:LAURA C KOCH WOODSTOCK LLC DBA FOUNTAIN VIEW DENTISTRY
Entity type:Organization
Organization Name:LAURA C KOCH WOODSTOCK LLC DBA FOUNTAIN VIEW DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-428-4058
Mailing Address - Street 1:1816 EAGLE DRIVE
Mailing Address - Street 2:BUILDING 200-A
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189
Mailing Address - Country:US
Mailing Address - Phone:770-926-0000
Mailing Address - Fax:
Practice Address - Street 1:1816 EAGLE DRIVE
Practice Address - Street 2:BUILDING 200-A
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189
Practice Address - Country:US
Practice Address - Phone:770-926-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty