Provider Demographics
NPI:1891579090
Name:KANG, JI WON (DMD)
Entity Type:Individual
Prefix:
First Name:JI
Middle Name:WON
Last Name:KANG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JIWON
Other - Middle Name:
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:13593 SW LIDEN DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2091
Mailing Address - Country:US
Mailing Address - Phone:971-517-9280
Mailing Address - Fax:
Practice Address - Street 1:4722 FAUNTLEROY WAY SW STE A
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4667
Practice Address - Country:US
Practice Address - Phone:206-928-6242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61435599122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist