Healthcare Provider Details

I. General information

NPI: 1629644364
Provider Name (Legal Business Name): MIN GOO KANG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/02/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4581 TOWNSHIP ROAD 634
MOUNT HOPE OH
44660-2501
US

IV. Provider business mailing address

PO BOX 20
KIDRON OH
44636-0020
US

V. Phone/Fax

Practice location:
  • Phone: 330-390-6006
  • Fax:
Mailing address:
  • Phone: 330-857-0144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.026534
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: