MEDICARE: BONHEE REBECCA KOO DMD

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	28703	TX

General Provider Information

NPI Number	:	1710299094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONHEE REBECCA KOO DMD

Provider Business Mailing Address
First Line	:	2142 N COLLINS ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-2877
Country	:	US
Telephone Number	:	682-560-4486
Fax Number	:

Provider Business Practice Location Address
First Line	:	2142 N COLLINS ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-2877
Country	:	US
Telephone Number	:	682-560-4486
Fax Number	:

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

Provider Enumeration Date	:	07/02/2010
Last Update Date	:	01/31/2017

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