Provider Demographics
NPI:1912550120
Name:KONG, EUN CHONG (DDS)
Entity Type:Individual
Prefix:
First Name:EUN CHONG
Middle Name:
Last Name:KONG
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 1:11501 SOCORRO RD
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:TX
Mailing Address - Zip Code:79927-3060
Mailing Address - Country:US
Mailing Address - Phone:915-603-4633
Mailing Address - Fax:
Practice Address - Street 1:11501 SOCORRO RD
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:TX
Practice Address - Zip Code:79927-3060
Practice Address - Country:US
Practice Address - Phone:915-603-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX354661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice