Provider Demographics
NPI:1659885473
Name:HA, KYOUNG TAE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KYOUNG TAE
Middle Name:
Last Name:HA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 W CARA DR
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6578
Mailing Address - Country:US
Mailing Address - Phone:714-873-6691
Mailing Address - Fax:
Practice Address - Street 1:439 S EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-1229
Practice Address - Country:US
Practice Address - Phone:714-873-6691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2024-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1020421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty