Provider Demographics
NPI:1386749224
Name:KOCH, ROBERT BENJAMIN (DMD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BENJAMIN
Last Name:KOCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:RB
Other - Middle Name:
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:1210 DRY HOLLOW RD STE 4
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3167
Mailing Address - Country:US
Mailing Address - Phone:541-298-4976
Mailing Address - Fax:541-298-2956
Practice Address - Street 1:1210 DRY HOLLOW RD STE 4
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3167
Practice Address - Country:US
Practice Address - Phone:541-298-4976
Practice Address - Fax:541-298-2956
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6280122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist