Jason Mantle Koch, D.M.D.
Individual provider Active NPI Dentist · St Mary, KY
NPI 1649459264 · NPPES record last updated Oct 31, 2007
Key facts
- NPI
- 1649459264
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 7252 (KY)
- Practice address
- 95 Raywick Rd
St Mary, KY 40063-8800 - Phone
- (270) 699-4074
- NPI assigned
- Oct 31, 2007
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 7252 | KY | MD | Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 7252 | KY | Yes |
Addresses
Primary practice location
95 Raywick Rd
St Mary, KY 40063-8800
Mailing address
100 Cambron Dr
Bardstown, KY 40004-2245
Phone (502) 460-2976
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 31, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.