Provider Demographics
NPI:1831104579
Name:KONG, KYONG A (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYONG
Middle Name:A
Last Name:KONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:A
Other - Last Name:KONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:825 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64124-2323
Mailing Address - Country:US
Mailing Address - Phone:816-474-4920
Mailing Address - Fax:816-889-1845
Practice Address - Street 1:825 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64124-2323
Practice Address - Country:US
Practice Address - Phone:816-474-4920
Practice Address - Fax:816-889-1845
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004000867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO409037009Medicaid
MOC16000075OtherMEDICARE PTAN