Provider Demographics
NPI:1124349659
Name:KOCH, HEATHER RENEE (DDS)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:RENEE
Last Name:KOCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 SW 123RD PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-6040
Mailing Address - Country:US
Mailing Address - Phone:405-640-5458
Mailing Address - Fax:
Practice Address - Street 1:1041 E STATE HIGHWAY 152
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-5117
Practice Address - Country:US
Practice Address - Phone:405-256-0037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6195122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist