Healthcare Provider Details

I. General information

NPI: 1629283262
Provider Name (Legal Business Name): RAYMOND KO D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 05/03/2010
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 TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number15321
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number37124
License Number StateCA

VIII. Authorized Official

Name: DR. RAYMOND A KO
Title or Position: OWNER
Credential: D.D.S.
Phone: 559-264-4543