Provider Demographics
NPI:1902943582
Name:KO, SUSAN SHAN SO (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:SHAN SO
Last Name:KO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10317 FINCH AVE
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-3412
Mailing Address - Country:US
Mailing Address - Phone:408-725-9233
Mailing Address - Fax:
Practice Address - Street 1:905 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-3339
Practice Address - Country:US
Practice Address - Phone:650-327-2310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA518721223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics