Healthcare Provider Details

I. General information

NPI: 1386522019
Provider Name (Legal Business Name): KUAN WEI TUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22731 NEWMAN ST STE 125
DEARBORN MI
48124-2023
US

IV. Provider business mailing address

200 E 21ST ST APT 6D
NEW YORK NY
10010-7400
US

V. Phone/Fax

Practice location:
  • Phone: 313-565-9118
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2901602796
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: