Provider Demographics
NPI:1396927828
Name:KOO, BRIAN S (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:S
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 1:201 S LIVINGSTON AVENE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039
Mailing Address - Country:US
Mailing Address - Phone:973-994-4200
Mailing Address - Fax:973-994-3933
Practice Address - Street 1:201 S LIVINGSTON AVENE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039
Practice Address - Country:US
Practice Address - Phone:973-994-4200
Practice Address - Fax:973-994-3933
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI023101001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02882626Medicaid