MEDICARE: GANG I KO DMD

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	DS040601	PA

General Provider Information

NPI Number	:	1568832913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GANG I KO DMD

Provider Business Mailing Address
First Line	:	4141 SPRUCE ST APT G1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-4071
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4141 SPRUCE ST APT G1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-4071
Country	:	US
Telephone Number	:	240-888-0620
Fax Number	:

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

Provider Enumeration Date	:	09/29/2015
Last Update Date	:	09/29/2015

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