Provider Demographics
NPI:1043441108
Name:KOPPENHAVER, JEREMY J (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:J
Last Name:KOPPENHAVER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 W 6TH STREET
Mailing Address - Street 2:BLDG 440
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:351 W 6TH STREET
Practice Address - Street 2:BLDG 440
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314
Practice Address - Country:US
Practice Address - Phone:912-435-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0380031223P0700X
PADS38003122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist