Active NPI
Eric J Koenig, DMD
- Dentist
- Nellis Afb, NV
National Provider Identifier
1255611901
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 10558
- Practice address
- 4700 Las Vegas Blvd N
Nellis Afb, NV 89191-6600 - Phone
- (702) 653-2600
- NPI assigned
- Aug 26, 2011
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 10558 | CO | Primary |
Addresses
Primary practice location
4700 Las Vegas Blvd N
Nellis Afb, NV 89191-6600
Mailing address
4700 Las Vegas Blvd N
Nellis Afb, NV 89191
Phone (702) 653-2600
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20180621000734 | CA | Order and Referring Only - Dentist | 7315292026 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 10558 | CO | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1314316800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1658361600000",
"number": "1255611901",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4700 LAS VEGAS BLVD N",
"city": "NELLIS AFB",
"state": "NV",
"postal_code": "89191",
"telephone_number": "702-653-2600"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4700 LAS VEGAS BLVD N",
"city": "NELLIS AFB",
"state": "NV",
"postal_code": "891916600",
"telephone_number": "702-653-2600"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KOENIG",
"first_name": "ERIC",
"middle_name": "J",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2011-08-26",
"last_updated": "2022-07-21",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "CO",
"license": "10558",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Nellis Afb, NV
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.