MEDICARE: ELIZABETH KOO D.D.S.

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	1223G0001X	General Practice Dentistry	057995	NY
2	1223G0001X	General Practice Dentistry	D010523	AZ

General Provider Information

NPI Number	:	1851715791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH KOO D.D.S.

Provider Business Mailing Address
First Line	:	2990 S 6TH AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85713-4705
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2990 S 6TH AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85713-4705
Country	:	US
Telephone Number	:	520-200-2985
Fax Number	:

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

Provider Enumeration Date	:	02/12/2014
Last Update Date	:	05/01/2020

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