Provider Demographics
NPI:1093238537
Name:KO, MIN JUNG (DDS)
Entity Type:Individual
Prefix:
First Name:MIN
Middle Name:JUNG
Last Name:KO
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 1:83 OCEAN BLVD APT 307
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:NH
Mailing Address - Zip Code:03842-3602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 WOODBURY AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-3250
Practice Address - Country:US
Practice Address - Phone:603-319-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH043341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice