Healthcare Provider Details

I. General information

NPI: 1851518807
Provider Name (Legal Business Name): BERNICE T. KO, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11340 W OLYMPIC BLVD #360
LOS ANGELES CA
90064-1608
US

IV. Provider business mailing address

11340 W OLYMPIC BLVD #360
LOS ANGELES CA
90064-1608
US

V. Phone/Fax

Practice location:
  • Phone: 310-473-2120
  • Fax:
Mailing address:
  • Phone: 310-473-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number40163
License Number StateCA

VIII. Authorized Official

Name: DR. BERNICE TAN KO
Title or Position: PRESIDENT
Credential:
Phone: 310-473-2120