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General NPI Number Information
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NPI Number | 1386052173
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Entity Type | Organization
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Legal Business Name | KIDS DENTAL STUDIO, PC
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Dates
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Enumeration Date | 07/24/2014
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Last Update Date | 07/24/2014
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Provider Practice Location Address
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Address Line | 21154 45TH DR 2ND FLOOR
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City | BAYSIDE
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State | NY
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Zip | 11361-3310
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Country | US
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Telephone | 718-428-3300
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Fax |
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Provider Business Mailing Address
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Address Line | 19669 45TH DR
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City | FLUSHING
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State | NY
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Zip | 11358-3509
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Country | US
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Telephone | 718-631-5515
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEN CHU
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Credential | DDS
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Telephone | 917-607-1028
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 047519
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License Number State | NY
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