Provider Demographics
NPI:1205245685
Name:KO, DIANE (DMD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 S BROADVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5725
Mailing Address - Country:US
Mailing Address - Phone:573-332-0808
Mailing Address - Fax:573-339-7945
Practice Address - Street 1:1314 BRENDA AVE
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-2303
Practice Address - Country:US
Practice Address - Phone:573-517-0405
Practice Address - Fax:573-517-0420
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014027291122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist