Healthcare Provider Details

I. General information

NPI: 1164250312
Provider Name (Legal Business Name): KIM HOANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 02/14/2025
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2370 W HAPPY VALLEY RD STE 1073
PHOENIX AZ
85085
US

IV. Provider business mailing address

18330 N 79TH AVE APT 2013
GLENDALE AZ
85308-8346
US

V. Phone/Fax

Practice location:
  • Phone: 623-281-1021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012249
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: