Healthcare Provider Details

I. General information

NPI: 1134819717
Provider Name (Legal Business Name): KO AND NAM DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 05/09/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 W FOOTHILL BLVD STE 138
UPLAND CA
91786-3693
US

IV. Provider business mailing address

3553 GRAYBURN RD
PASADENA CA
91107-4628
US

V. Phone/Fax

Practice location:
  • Phone: 909-303-3449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: MOON-HEE KO
Title or Position: DDS
Credential:
Phone: 213-700-9020