Provider Demographics
NPI:1851710511
Name:123 DENTAL GROUP PC
Entity Type:Organization
Organization Name:123 DENTAL GROUP PC
Other - Org Name:123 DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HYO-JIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-686-1115
Mailing Address - Street 1:123 E 37TH ST
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3030
Mailing Address - Country:US
Mailing Address - Phone:212-686-1115
Mailing Address - Fax:212-686-1142
Practice Address - Street 1:123 E 37TH ST
Practice Address - Street 2:SUITE 1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3030
Practice Address - Country:US
Practice Address - Phone:212-686-1115
Practice Address - Fax:212-686-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0558841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty