Healthcare Provider Details

I. General information

NPI: 1679770291
Provider Name (Legal Business Name): KYONG-YUN KONG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 LEES SUMMIT RD
KANSAS CITY MO
64139-1236
US

IV. Provider business mailing address

8634 NE 75TH TER
KANSAS CITY MO
64158-1270
US

V. Phone/Fax

Practice location:
  • Phone: 816-404-6885
  • Fax: 816-404-6903
Mailing address:
  • Phone: 816-509-7053
  • Fax: 816-415-3716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2006021867
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: