Healthcare Provider Details

I. General information

NPI: 1609056027
Provider Name (Legal Business Name): JING-YANG ELTON KO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JING YANG KO D.D.S.

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 ROUTE 46 W STE E101
FAIRFIELD NJ
07004-2488
US

IV. Provider business mailing address

271 ROUTE 46 W STE E101
FAIRFIELD NJ
07004-2488
US

V. Phone/Fax

Practice location:
  • Phone: 973-808-9820
  • Fax: 973-808-9730
Mailing address:
  • Phone: 973-808-9820
  • Fax: 973-808-9730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number15727
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: