Provider Demographics
NPI:1902231269
Name:MOK, DEREK (DDS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MOK
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:PO BOX 1534
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-7534
Mailing Address - Country:US
Mailing Address - Phone:561-463-0229
Mailing Address - Fax:
Practice Address - Street 1:2020 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-3120
Practice Address - Country:US
Practice Address - Phone:561-463-0229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62614122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist