Active NPI
Kunmin Roo
- Dentist
- Davenport, IA
National Provider Identifier
1083105878
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- DDS-09595
- Practice address
- 5025 Utica Ridge Rd Ste 103
Davenport, IA 52807-3035 - Phone
- (563) 345-8888
- Fax
- (888) 250-2562
- NPI assigned
- May 29, 2018
- Last updated
- Oct 31, 2019
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 019.031889 | IL | |
| Dentist | 122300000X | DDS-09595 | IA | Primary |
Addresses
Primary practice location
5025 Utica Ridge Rd Ste 103
Davenport, IA 52807-3035
Mailing address
3127 N University St
Peoria, IL 61604-1316
Phone (309) 681-8888
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DDS-09595 | IA | MD | Dentist |
| 019.031889 | IL | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Secure Dental LLC | Dentist | Past | Accepting new patients |
| Secure Dental II, LLC | Dentist | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Dentist
- Peoria, IL
- NPI 1154607422
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1527552000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1572480000000",
"number": "1083105878",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3127 N UNIVERSITY ST",
"city": "PEORIA",
"state": "IL",
"postal_code": "616041316",
"telephone_number": "309-681-8888",
"fax_number": "888-293-9991"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5025 UTICA RIDGE RD STE 103",
"city": "DAVENPORT",
"state": "IA",
"postal_code": "528073035",
"telephone_number": "563-345-8888",
"fax_number": "888-250-2562"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROO",
"first_name": "KUNMIN",
"name_prefix": "Dr.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2018-05-29",
"last_updated": "2019-10-31",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IL",
"license": "019.031889",
"primary": false
},
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IA",
"license": "DDS-09595",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Davenport, IA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.