Healthcare Provider Details

I. General information

NPI: 1962541474
Provider Name (Legal Business Name): KOAM DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 FARRINGTON ST
FLUSHING NY
11354-2826
US

IV. Provider business mailing address

3511 FARRINGTON ST
FLUSHING NY
11354-2826
US

V. Phone/Fax

Practice location:
  • Phone: 718-886-6677
  • Fax: 718-886-1413
Mailing address:
  • Phone: 718-886-6677
  • Fax: 718-886-1413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number037981-1
License Number StateNY

VIII. Authorized Official

Name: DR. GILBERT Y KIM
Title or Position: PRESIDENT
Credential: DDS
Phone: 718-886-6677