Basic Information
Provider Information | |||||||||
NPI: | 1356409817 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KI | ||||||||
FirstName: | ASHLEY | ||||||||
MiddleName: | YONSOOK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 85 S WEST ST | ||||||||
Address2: |   | ||||||||
City: | HOMER | ||||||||
State: | NY | ||||||||
PostalCode: | 130771542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077533797 | ||||||||
FaxNumber: | 6077536677 | ||||||||
Practice Location | |||||||||
Address1: | 23 CENTRAL ST | ||||||||
Address2: |   | ||||||||
City: | MORAVIA | ||||||||
State: | NY | ||||||||
PostalCode: | 131187709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6073440052 | ||||||||
FaxNumber: | 6073440056 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2006 | ||||||||
LastUpdateDate: | 01/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 048754 | NY | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 02543180 | 05 | NY |   | MEDICAID |