Healthcare Provider Details

I. General information

NPI: 1083953533
Provider Name (Legal Business Name): TIFFANY KUANG DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 07/13/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 MAIN ST STE C
GROTON MA
01450-1388
US

IV. Provider business mailing address

489 MAIN ST STE C
GROTON MA
01450-1388
US

V. Phone/Fax

Practice location:
  • Phone: 978-708-0080
  • Fax: 978-708-0081
Mailing address:
  • Phone: 516-304-0250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI02565400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02565400
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: