Provider Demographics
NPI:1568832913
Name:KO, GANG I (DMD)
Entity Type:Individual
Prefix:
First Name:GANG
Middle Name:I
Last Name:KO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:KANG
Other - Middle Name:I
Other - Last Name:KO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:4141 SPRUCE ST APT G1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4141 SPRUCE ST APT G1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4071
Practice Address - Country:US
Practice Address - Phone:240-888-0620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040601122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist