MEDICARE: HAYEON KOO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	22DI027668800	NJ

General Provider Information

NPI Number	:	1326545377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAYEON KOO

Provider Business Mailing Address
First Line	:	1315 ANDERSON AVE STE A
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-1732
Country	:	US
Telephone Number	:	201-305-9808
Fax Number	:

Provider Business Practice Location Address
First Line	:	1315 ANDERSON AVE STE A
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-1732
Country	:	US
Telephone Number	:	13-059-8082
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2018
Last Update Date	:	01/14/2020

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Directions to “ HAYEON KOO ” Practice Location

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