1104940840 NPI number — DR. PHILIP I KOH DDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104940840 NPI number — DR. PHILIP I KOH DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOH
Provider First Name:
PHILIP
Provider Middle Name:
I
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOH
Provider Other First Name:
ILWOONG
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104940840
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14016 SULLYFIELD CIR STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANTILLY
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20151-4010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-815-0699
Provider Business Mailing Address Fax Number:
703-815-0692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14016 SULLYFIELD CIR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHANTILLY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20151-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-815-0699
Provider Business Practice Location Address Fax Number:
703-815-0692
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2901019018 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 2901019018 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1958112110 . This is a "BCBS OF MI MED SURGICAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: D910180 . This is a "BCBS OF MI DENTAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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