Provider Demographics
NPI:1962482562
Name:BAN, MICHAEL KIM (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KIM
Last Name:BAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:15074-1911
Mailing Address - Country:US
Mailing Address - Phone:724-774-2220
Mailing Address - Fax:
Practice Address - Street 1:450 ADAMS ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:PA
Practice Address - Zip Code:15074-1911
Practice Address - Country:US
Practice Address - Phone:724-774-2220
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022496L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008772510001Medicaid
PA0008772510001Medicaid