MEDICARE: KJK ORTHODONTICS PC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DS030955L	PA

General Provider Information

NPI Number	:	1689700098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KJK ORTHODONTICS PC

Provider Business Mailing Address
First Line	:	6814 CASTOR AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-2106
Country	:	US
Telephone Number	:	215-745-9443
Fax Number	:	215-745-9453

Provider Business Practice Location Address
First Line	:	6814 CASTOR AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-2106
Country	:	US
Telephone Number	:	215-745-9443
Fax Number	:	215-745-9453

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEVIN JOHN KLATTE
Credential	:	DMD
Telephone Number	:	215-745-9443

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	08/22/2020

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