Provider Demographics
NPI:1982210423
Name:WANG, KEVIN (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 JEFFREY DR NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-0847
Mailing Address - Country:US
Mailing Address - Phone:856-313-7484
Mailing Address - Fax:
Practice Address - Street 1:51ST MEDICAL GROUP, UNIT 2060, APO AP
Practice Address - Street 2:
Practice Address - City:PYEONGTAEK-SI
Practice Address - State:SOUTH KOREA
Practice Address - Zip Code:96278
Practice Address - Country:KR
Practice Address - Phone:856-313-7484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11905878-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist