Healthcare Provider Details

I. General information

NPI: 1336395821
Provider Name (Legal Business Name): SOO KANG D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 08/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 PROSPECT AVE STE 1
HACKENSACK NJ
07601-2257
US

IV. Provider business mailing address

227B 3RD ST
PALISADES PARK NJ
07650
US

V. Phone/Fax

Practice location:
  • Phone: 201-970-6833
  • Fax:
Mailing address:
  • Phone: 201-970-6833
  • Fax: 201-820-3603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02192800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: