Provider Demographics
NPI:1902414105
Name:KANG, SU JUNG (DDS)
Entity Type:Individual
Prefix:
First Name:SU JUNG
Middle Name:
Last Name:KANG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12362 AZURE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2991
Mailing Address - Country:US
Mailing Address - Phone:703-304-3538
Mailing Address - Fax:
Practice Address - Street 1:5275 LEESBURG PIKE BUILDING 7
Practice Address - Street 2:SUITE 100
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22041
Practice Address - Country:US
Practice Address - Phone:703-935-2878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014169991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice