Provider Demographics
NPI:1932632726
Name:KANG, JEAN
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:KANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-1201
Mailing Address - Country:US
Mailing Address - Phone:909-618-5240
Mailing Address - Fax:
Practice Address - Street 1:1808 VERDUGO BLVD STE 312
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1456
Practice Address - Country:US
Practice Address - Phone:818-790-6721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1036521223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
103652OtherDENTAL LICENSE
FK8687254OtherDEA NUMBER