Provider Demographics
NPI:1912631235
Name:KONG, JONG MIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONG MIN
Middle Name:
Last Name:KONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 MONGOOSE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-1055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 E 17TH ST STE 15
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3845
Practice Address - Country:US
Practice Address - Phone:714-224-0480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS107534122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist