Healthcare Provider Details

I. General information

NPI: 1417174467
Provider Name (Legal Business Name): DR. BERNICE TAN KO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 LINCOLN BLVD
VENICE CA
90291-2842
US

IV. Provider business mailing address

10317 MISSOURI AVE #1
LOS ANGELES CA
90025-5080
US

V. Phone/Fax

Practice location:
  • Phone: 310-392-4103
  • Fax:
Mailing address:
  • Phone: 310-557-2712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: