=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225413511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CINDY KONG DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2015
-----------------------------------------------------
Last Update Date | 07/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 OLD DEERFIELD PIKE
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08302-3703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-455-7014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 OLD DEERFIELD PIKE
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08302-3703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-455-7014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DI02608300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS040391
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------