Provider Demographics
NPI:1225758253
Name:KOO, MINNIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MINNIE
Middle Name:
Last Name:KOO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 JOPLIN RD APT 2207
Mailing Address - Street 2:
Mailing Address - City:KENNEDALE
Mailing Address - State:TX
Mailing Address - Zip Code:76060-6249
Mailing Address - Country:US
Mailing Address - Phone:702-376-7358
Mailing Address - Fax:
Practice Address - Street 1:287 FRONTAGE RD SUITE 160
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-405-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38916122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist