Provider Demographics
NPI:1689820680
Name:O, MINSOO (DMD)
Entity Type:Individual
Prefix:DR
First Name:MINSOO
Middle Name:
Last Name:O
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840-1411
Mailing Address - Country:US
Mailing Address - Phone:954-330-1955
Mailing Address - Fax:
Practice Address - Street 1:314 ESSEX ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1411
Practice Address - Country:US
Practice Address - Phone:954-330-1955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice