Provider Demographics
NPI:1386021954
Name:KO DENTAL CARE P.C.
Entity Type:Organization
Organization Name:KO DENTAL CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAE
Authorized Official - Middle Name:
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-220-5353
Mailing Address - Street 1:2840 W BERWYN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3402
Mailing Address - Country:US
Mailing Address - Phone:872-208-7573
Mailing Address - Fax:872-806-0113
Practice Address - Street 1:3434 W PETERSON AVE
Practice Address - Street 2:SUITE 1D
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3319
Practice Address - Country:US
Practice Address - Phone:872-208-7573
Practice Address - Fax:872-806-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-02
Last Update Date:2015-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190274851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty