Provider Demographics
NPI:1114147360
Name:KANG, JASON C
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:C
Last Name:KANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 WILSHIRE BLVD
Mailing Address - Street 2:#110
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1118
Mailing Address - Country:US
Mailing Address - Phone:213-385-5097
Mailing Address - Fax:213-480-0374
Practice Address - Street 1:3055 WILSHIRE BLVD
Practice Address - Street 2:#110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1118
Practice Address - Country:US
Practice Address - Phone:213-385-5097
Practice Address - Fax:213-480-0374
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA520681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice