Healthcare Provider Details

I. General information

NPI: 1003496316
Provider Name (Legal Business Name): CHUNWOO KANG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2021
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CAMINO DE SALUD NE
ALBUQUERQUE NM
87102-4516
US

IV. Provider business mailing address

8415 CHATEAU DR NE
ALBUQUERQUE NM
87122-4204
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-4031
  • Fax:
Mailing address:
  • Phone: 505-238-8632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTD-00-137
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD5469
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: