Provider Demographics
NPI:1093912982
Name:KOO, SAMUEL (DMD, MS, DMSC)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:KOO
Suffix:
Gender:M
Credentials:DMD, MS, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 CONCORD ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1314
Mailing Address - Country:US
Mailing Address - Phone:617-223-7750
Mailing Address - Fax:
Practice Address - Street 1:386 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY HILLS
Practice Address - State:MA
Practice Address - Zip Code:02481-6213
Practice Address - Country:US
Practice Address - Phone:781-235-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18579171223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics