Provider Demographics
NPI:1538779780
Name:KANG, HEEYUN
Entity type:Individual
Prefix:
First Name:HEEYUN
Middle Name:
Last Name:KANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 FOLSOM ST APT 405
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-4388
Mailing Address - Country:US
Mailing Address - Phone:415-819-1344
Mailing Address - Fax:
Practice Address - Street 1:1153 W PACHECO BLVD
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-8617
Practice Address - Country:US
Practice Address - Phone:209-383-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS105095122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist