Healthcare Provider Details

I. General information

NPI: 1770817199
Provider Name (Legal Business Name): ANNABEL SY KOA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N SAN MATEO DR SUITE #2
SAN MATEO CA
94401-2418
US

IV. Provider business mailing address

400 N SAN MATEO DR SUITE #2
SAN MATEO CA
94401-2418
US

V. Phone/Fax

Practice location:
  • Phone: 650-343-0895
  • Fax: 650-343-2441
Mailing address:
  • Phone: 650-343-0895
  • Fax: 650-343-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberFK1262803
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS52877
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: