Provider Demographics
NPI:1548618580
Name:KANG, HYO S. DMD INC.
Entity Type:Organization
Organization Name:KANG, HYO S. DMD INC.
Other - Org Name:WELLSPRING DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HYO
Authorized Official - Middle Name:S
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:925-336-9611
Mailing Address - Street 1:8051 BRIAR OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5196
Mailing Address - Country:US
Mailing Address - Phone:925-336-9611
Mailing Address - Fax:
Practice Address - Street 1:1700 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE D
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3588
Practice Address - Country:US
Practice Address - Phone:925-336-9611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA560411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1972793651OtherNATIONAL NPI