Provider Demographics
NPI:1477640498
Name:JO, KEN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:J
Last Name:JO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:KEN
Other - Middle Name:JIN HO
Other - Last Name:CHO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:618TH DENTAL COMPANY(AS), USA DENTAC-KOREA, UNIT #15652
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-5652
Mailing Address - Country:US
Mailing Address - Phone:0118227-917-9061
Mailing Address - Fax:0118227-916-7703
Practice Address - Street 1:618TH DENTAL COMPANY(AS)
Practice Address - Street 2:USA DENTAC-KOREA, UNIT #15652
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-5652
Practice Address - Country:US
Practice Address - Phone:0118227-917-9061
Practice Address - Fax:0118227-916-7703
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048045-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice