Provider Demographics
NPI:1063664365
Name:HEW, ELLSWORTH YIN KONG (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:ELLSWORTH
Middle Name:YIN KONG
Last Name:HEW
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:ELLSWORTH
Other - Middle Name:YIN KONG
Other - Last Name:HEW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ELLSWORTH HEW
Mailing Address - Street 1:255 W COURT ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2986
Mailing Address - Country:US
Mailing Address - Phone:530-661-7799
Mailing Address - Fax:530-661-7112
Practice Address - Street 1:255 W COURT ST
Practice Address - Street 2:SUITE A
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2986
Practice Address - Country:US
Practice Address - Phone:530-661-7799
Practice Address - Fax:530-661-7112
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247961223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics