Healthcare Provider Details

I. General information

NPI: 1558639054
Provider Name (Legal Business Name): PHUNG KIM HOANG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN P. K. HOANG DDS

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E 40TH ST SUITE 1203
NEW YORK NY
10016-1201
US

IV. Provider business mailing address

30 E 40TH ST SUITE 1203
NEW YORK NY
10016-1201
US

V. Phone/Fax

Practice location:
  • Phone: 212-684-6759
  • Fax: 212-684-6758
Mailing address:
  • Phone: 212-684-6759
  • Fax: 212-684-6758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number045107
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: