=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386868453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINGA KOSTOLOWSKA, D.M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2409 E ALLEGHENY AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19134-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-634-9151
-----------------------------------------------------
Fax | 215-634-7723
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2409 E ALLEGHENY AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19134-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-634-9151
-----------------------------------------------------
Fax | 215-634-7723
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KINGA KOSTOLOWSKA
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 215-634-9151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS028239L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------