MEDICARE: KANG HO KU D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	51097	CA

General Provider Information

NPI Number	:	1477737559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANG HO KU D.D.S

Provider Business Mailing Address
First Line	:	266 S HARVARD BLVD
Second Line	:	110
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-4372
Country	:	US
Telephone Number	:	213-380-2727
Fax Number	:	213-380-2822

Provider Business Practice Location Address
First Line	:	266 S HARVARD BLVD
Second Line	:	110
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-4372
Country	:	US
Telephone Number	:	213-380-2727
Fax Number	:	213-380-2822

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/24/2007
Last Update Date	:	12/24/2007

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