Provider Demographics
NPI:1003827395
Name:KOH DENTAL CORPORATION
Entity Type:Organization
Organization Name:KOH DENTAL CORPORATION
Other - Org Name:PHILIP D KOH DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:D
Authorized Official - Last Name:KOH
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-835-8797
Mailing Address - Street 1:2509 W MCFADDEN AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-2747
Mailing Address - Country:US
Mailing Address - Phone:714-835-8797
Mailing Address - Fax:714-835-8798
Practice Address - Street 1:2509 W MCFADDEN AVE
Practice Address - Street 2:SUITE E
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-2747
Practice Address - Country:US
Practice Address - Phone:714-835-8797
Practice Address - Fax:714-835-8797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3712501122300000X
CA53415122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G9379501Medicare UPIN