Provider Demographics
NPI:1467093419
Name:KOOK, TIMOTHY (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:KOOK
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 1:173 N MARENGO AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-4520
Mailing Address - Country:US
Mailing Address - Phone:925-451-5649
Mailing Address - Fax:
Practice Address - Street 1:813 FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2605
Practice Address - Country:US
Practice Address - Phone:925-451-5649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104316122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist