Provider Demographics
NPI:1124766423
Name:KOERNER, MICHAEL DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:KOERNER
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22201 MOROSS
Mailing Address - Street 2:PROFESSIONAL BUILDING II, SUITE 155
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236
Mailing Address - Country:US
Mailing Address - Phone:313-499-4775
Mailing Address - Fax:313-499-4952
Practice Address - Street 1:22201 MOROSS
Practice Address - Street 2:PROFESSIONAL BUILDING II, SUITE 155
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:313-499-4775
Practice Address - Fax:313-499-4952
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
PADS043703122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program