Provider Demographics
NPI:1982087169
Name:KO, ALICE (DMD)
Entity Type:Individual
Prefix:
First Name:ALICE
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 1:5119 104TH ST SW
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-4427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3815 S M ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-3933
Practice Address - Country:US
Practice Address - Phone:253-476-8003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60576366122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist