Provider Demographics
NPI:1770965535
Name:SAMUEL H. KO, DDS, INC.
Entity type:Organization
Organization Name:SAMUEL H. KO, DDS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-952-3756
Mailing Address - Street 1:12429 MARIPOSA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-6017
Mailing Address - Country:US
Mailing Address - Phone:760-952-3756
Mailing Address - Fax:760-952-1008
Practice Address - Street 1:12429 MARIPOSA RD
Practice Address - Street 2:SUITE A
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-6017
Practice Address - Country:US
Practice Address - Phone:760-952-3756
Practice Address - Fax:760-952-1008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA404541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty