Provider Demographics
NPI:1326400748
Name:KOBAWOO DENTAL CENTER
Entity Type:Organization
Organization Name:KOBAWOO DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HE-KYUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM-YU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-362-3000
Mailing Address - Street 1:1222 WELSH RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-2054
Mailing Address - Country:US
Mailing Address - Phone:215-362-3000
Mailing Address - Fax:267-263-1499
Practice Address - Street 1:1222 WELSH RD
Practice Address - Street 2:SUITE G
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-2054
Practice Address - Country:US
Practice Address - Phone:215-362-3000
Practice Address - Fax:267-263-1499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026455L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026469620001Medicaid