MEDICARE: DR. TIMOTHY KOOK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	104316	CA

General Provider Information

NPI Number	:	1467093419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY KOOK DDS

Provider Business Mailing Address
First Line	:	173 N MARENGO AVE APT 204
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91101-4520
Country	:	US
Telephone Number	:	925-451-5649
Fax Number	:

Provider Business Practice Location Address
First Line	:	813 FAIR OAKS AVE
Second Line	:
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91030-2605
Country	:	US
Telephone Number	:	925-451-5649
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/01/2019
Last Update Date	:	01/28/2020

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