Provider Demographics
NPI:1841546314
Name:NG, KEVIN GARSON (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GARSON
Last Name:NG
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 1:4620 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625
Mailing Address - Country:US
Mailing Address - Phone:708-552-0275
Mailing Address - Fax:
Practice Address - Street 1:4620 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:708-552-0275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019-0294621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program