Provider Demographics
NPI:1033623822
Name:VANG, MY PANG KOU (M)
Entity Type:Individual
Prefix:
First Name:MY PANG
Middle Name:KOU
Last Name:VANG
Suffix:
Gender:F
Credentials:M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 WINIFRED ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2424
Mailing Address - Country:US
Mailing Address - Phone:651-226-5110
Mailing Address - Fax:
Practice Address - Street 1:1590 ROBERT ST S
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3403
Practice Address - Country:US
Practice Address - Phone:651-300-0949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT84125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist