MEDICARE: DR. KASSYNI PANGDRA YANG DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D1234	MN

General Provider Information

NPI Number	:	1588959860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KASSYNI PANGDRA YANG DDS

Provider Business Mailing Address
First Line	:	8511 JEFFERSON LN N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55445-2121
Country	:	US
Telephone Number	:	763-205-0526
Fax Number	:

Provider Business Practice Location Address
First Line	:	8511 JEFFERSON LN N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55445-2121
Country	:	US
Telephone Number	:	763-205-0526
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2011
Last Update Date	:	10/25/2015

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