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General NPI Number Information
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NPI Number | 1013106830
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Entity Type | Individual
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Provider Name | JAE KO DDS
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Gender | Male
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Dates
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Enumeration Date | 10/17/2007
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Last Update Date | 05/02/2015
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Provider Practice Location Address
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Address Line | 3434 W PETERSON AVE SUITE 1D
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City | CHICAGO
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State | IL
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Zip | 60659-3319
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Country | US
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Telephone | 872-208-7573
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Fax | 872-806-0113
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Provider Business Mailing Address
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Address Line | 2840 W BERWYN AVE
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City | CHICAGO
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State | IL
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Zip | 60625-3402
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Country | US
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Telephone | 646-220-5353
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019027485
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License Number State | IL
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