Healthcare Provider Details

I. General information

NPI: 1194042309
Provider Name (Legal Business Name): EUGENE MYUNG KO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 S 40TH ST
PHILADELPHIA PA
19104-6030
US

IV. Provider business mailing address

240 S 40TH ST
PHILADELPHIA PA
19104-6030
US

V. Phone/Fax

Practice location:
  • Phone: 215-537-8177
  • Fax:
Mailing address:
  • Phone: 215-573-8177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021194
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number056653
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number2901021194
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2901021194
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: