Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DS037564 | PA |
N | 1223X0400X | Orthodontists | 61538 | CA |
NPI | 1013171396 |
---|---|
Provider Name | Mr. Hyung Kwon Ko |
First Address | Oakland, CA 94611-5665 |
Second Address | Oakland, CA 94611-5665 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2008 |
Last Update Date | 10/12/2012 |