Provider Demographics
NPI:1295350163
Name:KOO, JUNG-HWA AILEEN
Entity type:Individual
Prefix:
First Name:JUNG-HWA
Middle Name:AILEEN
Last Name:KOO
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 1:1900 S EADS ST APT 928
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-3045
Mailing Address - Country:US
Mailing Address - Phone:703-963-9160
Mailing Address - Fax:
Practice Address - Street 1:1212 W BROAD ST
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-2116
Practice Address - Country:US
Practice Address - Phone:703-519-6697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN1002152122300000X
VA0401417143122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist