Provider Demographics
NPI:1598924292
Name:KOO, SONG HOE
Entity Type:Individual
Prefix:
First Name:SONG
Middle Name:HOE
Last Name:KOO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 S BREA CANYON RD
Mailing Address - Street 2:STE #210
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765
Mailing Address - Country:US
Mailing Address - Phone:909-396-0077
Mailing Address - Fax:909-396-0071
Practice Address - Street 1:2040 S BREA CANYON RD
Practice Address - Street 2:STE #210
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765
Practice Address - Country:US
Practice Address - Phone:909-396-0077
Practice Address - Fax:909-396-0071
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA510961223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics