Provider Demographics
NPI:1649280421
Name:KOOB, ANTONIA PEREGONOV (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTONIA
Middle Name:PEREGONOV
Last Name:KOOB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 MERION CV
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-6231
Mailing Address - Country:US
Mailing Address - Phone:512-238-9742
Mailing Address - Fax:512-733-5600
Practice Address - Street 1:2500 W PARMER LN
Practice Address - Street 2:SUITE 140
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-4233
Practice Address - Country:US
Practice Address - Phone:512-837-6100
Practice Address - Fax:512-733-5600
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice