Healthcare Provider Details

I. General information

NPI: 1023108107
Provider Name (Legal Business Name): AYE K. KO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RAYMOND A.K. KO D.D.S.

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 N FRESNO ST
FRESNO CA
93703-3708
US

IV. Provider business mailing address

1409 N FRESNO ST
FRESNO CA
93703-3708
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-4543
  • Fax: 559-264-0226
Mailing address:
  • Phone: 559-264-4543
  • Fax: 559-264-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number37124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: