Healthcare Provider Details

I. General information

NPI: 1689700098
Provider Name (Legal Business Name): KJK ORTHODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6814 CASTOR AVE
PHILADELPHIA PA
19149-2106
US

IV. Provider business mailing address

6814 CASTOR AVE
PHILADELPHIA PA
19149-2106
US

V. Phone/Fax

Practice location:
  • Phone: 215-745-9443
  • Fax: 215-745-9453
Mailing address:
  • Phone: 215-745-9443
  • Fax: 215-745-9453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS030955L
License Number StatePA

VIII. Authorized Official

Name: DR. KEVIN JOHN KLATTE
Title or Position: PRESIDENT
Credential: DMD
Phone: 215-745-9443