Provider Demographics
NPI:1184243420
Name:KO, SOONA
Entity type:Individual
Prefix:
First Name:SOONA
Middle Name:
Last Name:KO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-1934
Mailing Address - Country:US
Mailing Address - Phone:714-571-3672
Mailing Address - Fax:
Practice Address - Street 1:1357 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-1934
Practice Address - Country:US
Practice Address - Phone:714-571-3672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1071261223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program