Provider Demographics
NPI:1013577063
Name:KANG, JACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:KANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7965 COUNTRY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-2770
Mailing Address - Country:US
Mailing Address - Phone:901-647-3386
Mailing Address - Fax:
Practice Address - Street 1:919 CONFERENCE DR STE 5
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1924
Practice Address - Country:US
Practice Address - Phone:615-855-0087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11046122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist