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NPI Code Detail

MEDICARE: KO DENTAL CARE P.C.

MEDICARE: KO DENTAL CARE P.C.
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
11223G0001XGeneral Practice Dentistry019027485IL

General Provider Information

NPI Number : 1386021954
Entity Type Code : Organization
Provider Name (Legal Business Name) : KO DENTAL CARE P.C.
Provider Business Mailing Address
First Line : 2840 W BERWYN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60625-3402
Country : US
Telephone Number : 872-208-7573
Fax Number : 872-806-0113
Provider Business Practice Location Address
First Line : 3434 W PETERSON AVE
Second Line : SUITE 1D
City : CHICAGO
State : IL
Zip : 60659-3319
Country : US
Telephone Number : 872-208-7573
Fax Number : 872-806-0113
Authorized Official
Title or Position : PRESIDENT
Name : JAE KO
Credential : DDS
Telephone Number : 646-220-5353
Provider Enumeration Date : 05/02/2015
Last Update Date : 05/02/2015

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Directions to “KO DENTAL CARE P.C. ” Practice Location

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