Provider Demographics
NPI:1760523930
Name:KOO, JOHNNY HEEJOON (DDS)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:HEEJOON
Last Name:KOO
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 1:40820 WINCHESTER RD
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-5525
Mailing Address - Country:US
Mailing Address - Phone:951-296-6788
Mailing Address - Fax:
Practice Address - Street 1:40820 WINCHESTER RD
Practice Address - Street 2:1500
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5525
Practice Address - Country:US
Practice Address - Phone:951-296-6788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA520731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice