Provider Demographics
NPI:1760525968
Name:KANG, HEENAM (DDS)
Entity Type:Individual
Prefix:
First Name:HEENAM
Middle Name:
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 1:2234A SOUTH EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-6501
Mailing Address - Country:US
Mailing Address - Phone:909-986-6866
Mailing Address - Fax:909-986-1053
Practice Address - Street 1:2234A SOUTH EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-6501
Practice Address - Country:US
Practice Address - Phone:909-986-6866
Practice Address - Fax:909-986-1053
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29319122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2931901OtherDENTI CAL