MEDICARE: DR. HEAMO LEE KOO D.D.S.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	19854	TX

General Provider Information

NPI Number	:	1548465610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEAMO LEE KOO D.D.S.

Provider Business Mailing Address
First Line	:	4324 OLEANDER ST
Second Line	:
City	:	BELLAIRE
State	:	TX
Zip	:	77401-5227
Country	:	US
Telephone Number	:	713-661-9472
Fax Number	:

Provider Business Practice Location Address
First Line	:	2450 FONDREN RD STE 320
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77063-2320
Country	:	US
Telephone Number	:	713-783-3116
Fax Number	:

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

Provider Enumeration Date	:	06/19/2007
Last Update Date	:	07/08/2007

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