Provider Demographics
NPI:1922362607
Name:KANG, AMANDEEP KAUR
Entity Type:Individual
Prefix:
First Name:AMANDEEP
Middle Name:KAUR
Last Name:KANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7247 SANDPIPER ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-7853
Mailing Address - Country:US
Mailing Address - Phone:269-599-7630
Mailing Address - Fax:
Practice Address - Street 1:3205 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3301
Practice Address - Country:US
Practice Address - Phone:773-267-2671
Practice Address - Fax:773-267-2628
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029084122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist