Healthcare Provider Details

I. General information

NPI: 1154593150
Provider Name (Legal Business Name): 18TH AVE PROFESSIONAL DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2171 68TH ST FL 3
BROOKLYN NY
11204-4733
US

IV. Provider business mailing address

2171 68TH ST FL 3
BROOKLYN NY
11204-4733
US

V. Phone/Fax

Practice location:
  • Phone: 347-713-1828
  • Fax: 347-713-1878
Mailing address:
  • Phone: 347-713-1828
  • Fax: 347-713-1878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number049610
License Number StateNY

VIII. Authorized Official

Name: KENNY H HO
Title or Position: DDS/OWNER
Credential: DDS
Phone: 347-713-1828