Provider Demographics
NPI:1720175300
Name:KOO, DAVID C (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
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 1:111 E LIVE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-5240
Mailing Address - Country:US
Mailing Address - Phone:626-445-1181
Mailing Address - Fax:
Practice Address - Street 1:111 E LIVE OAK AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-5240
Practice Address - Country:US
Practice Address - Phone:626-445-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35925122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist