Provider Demographics
NPI:1669908620
Name:KS DENTISTRY
Entity type:Organization
Organization Name:KS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-524-5622
Mailing Address - Street 1:360 W 43RD ST APT S6A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-6486
Mailing Address - Country:US
Mailing Address - Phone:917-524-5622
Mailing Address - Fax:
Practice Address - Street 1:360 W 43RD ST APT S6A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-6486
Practice Address - Country:US
Practice Address - Phone:917-524-5622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50-0555361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03427369Medicaid