Provider Demographics
NPI:1497381842
Name:FAMILY DENTISTRY OF EPHRATA
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF EPHRATA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YOOSON
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:717-738-0124
Mailing Address - Street 1:1065 SHARP AVE
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-1135
Mailing Address - Country:US
Mailing Address - Phone:717-738-0124
Mailing Address - Fax:717-721-1043
Practice Address - Street 1:1065 SHARP AVE
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1135
Practice Address - Country:US
Practice Address - Phone:717-738-0124
Practice Address - Fax:717-721-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023088408OtherINDIVIDUAL NPI