Provider Demographics
NPI:1346235397
Name:KANG, HAN JONG (DDS)
Entity Type:Individual
Prefix:MR
First Name:HAN
Middle Name:JONG
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 1:777 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07657-1001
Mailing Address - Country:US
Mailing Address - Phone:201-945-0123
Mailing Address - Fax:201-313-5252
Practice Address - Street 1:777 BROAD AVE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657-1001
Practice Address - Country:US
Practice Address - Phone:201-945-0123
Practice Address - Fax:201-313-5252
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02113001223G0001X
NY0487681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02064120Medicaid