Provider Demographics
NPI:1336832641
Name:SOUTH WINDSOR PERIO, PLLC
Entity Type:Organization
Organization Name:SOUTH WINDSOR PERIO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-714-6929
Mailing Address - Street 1:469 BUCKLAND RD STE 203
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3737
Mailing Address - Country:US
Mailing Address - Phone:860-644-2340
Mailing Address - Fax:
Practice Address - Street 1:469 BUCKLAND RD STE 203
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3737
Practice Address - Country:US
Practice Address - Phone:860-644-2340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty