Healthcare Provider Details

I. General information

NPI: 1710396908
Provider Name (Legal Business Name): KENNETH JANG DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 VISTA DEL LAGO DR #11
VALLEY SPRINGS CA
95252-9294
US

IV. Provider business mailing address

8228 CRYSTAL WALK CIR
ELK GROVE CA
95758-8081
US

V. Phone/Fax

Practice location:
  • Phone: 209-772-0375
  • Fax:
Mailing address:
  • Phone: 909-553-8390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60901
License Number StateCA

VIII. Authorized Official

Name: KENNETH JANG
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 909-553-8390