Healthcare Provider Details

I. General information

NPI: 1043428253
Provider Name (Legal Business Name): YONG-HAN KOO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2007
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 BOSTON POST RD STE 2
WAYLAND MA
01778-1836
US

IV. Provider business mailing address

241 BOSTON POST RD STE 2
WAYLAND MA
01778-1836
US

V. Phone/Fax

Practice location:
  • Phone: 508-276-1222
  • Fax:
Mailing address:
  • Phone: 508-276-1222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN22058
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: