Healthcare Provider Details

I. General information

NPI: 1649185851
Provider Name (Legal Business Name): SANGWON KANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-8355
US

IV. Provider business mailing address

1736 MANNING DR # 2
CLARKSVILLE TN
37042-7959
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number142988109926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: