Provider Demographics
NPI:1255066890
Name:KONG, BO-HSIN (DDS)
Entity type:Individual
Prefix:DR
First Name:BO-HSIN
Middle Name:
Last Name:KONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:EUNICE
Other - Middle Name:BO-HSIN
Other - Last Name:KONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:25 W RANDOLPH ST APT 2406
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-3525
Mailing Address - Country:US
Mailing Address - Phone:515-520-2272
Mailing Address - Fax:
Practice Address - Street 1:1192 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2715
Practice Address - Country:US
Practice Address - Phone:219-226-3189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190339011223G0001X
IN12014160A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty