Healthcare Provider Details

I. General information

NPI: 1568400950
Provider Name (Legal Business Name): SANGKYU - HAN D.D.S.,M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 W COLLEGE AVE
APPLETON WI
54913-8507
US

IV. Provider business mailing address

4117 N TERRAVIEW DR
APPLETON WI
54913-6315
US

V. Phone/Fax

Practice location:
  • Phone: 920-730-0345
  • Fax:
Mailing address:
  • Phone: 920-205-0515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4244-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: