Provider Demographics
NPI:1013297795
Name:KONG, NAMIE (DMD)
Entity type:Individual
Prefix:DR
First Name:NAMIE
Middle Name:
Last Name:KONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20700 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3701
Mailing Address - Country:US
Mailing Address - Phone:323-564-2444
Mailing Address - Fax:
Practice Address - Street 1:20700 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3701
Practice Address - Country:US
Practice Address - Phone:323-564-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA645771223P0221X
TX272711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice