Provider Demographics
NPI:1063690436
Name:BOB KOENITZER DDS, INC.
Entity type:Organization
Organization Name:BOB KOENITZER DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KOENITZER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-766-6666
Mailing Address - Street 1:101 LYNCH CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-8301
Mailing Address - Country:US
Mailing Address - Phone:707-766-6666
Mailing Address - Fax:707-763-1614
Practice Address - Street 1:101 LYNCH CREEK WAY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-8301
Practice Address - Country:US
Practice Address - Phone:707-766-6666
Practice Address - Fax:707-763-1614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA346241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty