Provider Demographics
NPI:1679853063
Name:KOH, MYUNGSUK (DMD)
Entity type:Individual
Prefix:DR
First Name:MYUNGSUK
Middle Name:
Last Name:KOH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 LAUDERDALE DR
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1082
Mailing Address - Country:US
Mailing Address - Phone:804-913-1710
Mailing Address - Fax:
Practice Address - Street 1:302 JAMERSON CT
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5678
Practice Address - Country:US
Practice Address - Phone:781-535-2834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413547122300000X
MADN18558391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice