Provider Demographics
NPI:1699803049
Name:KOO, BERNARD (DDS)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:
Last Name:KOO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 ATOLL
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3383
Mailing Address - Country:US
Mailing Address - Phone:626-960-9660
Mailing Address - Fax:
Practice Address - Street 1:420 ORD ST
Practice Address - Street 2:SUITE 102-A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2834
Practice Address - Country:US
Practice Address - Phone:213-617-0136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist