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General NPI Number Information
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NPI Number | 1336832641
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Entity Type | Organization
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Legal Business Name | SOUTH WINDSOR PERIO, PLLC
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Dates
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Enumeration Date | 06/01/2023
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Last Update Date | 06/01/2023
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Provider Practice Location Address
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Address Line | 469 BUCKLAND RD STE 203
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City | SOUTH WINDSOR
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State | CT
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Zip | 06074-3737
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Country | US
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Telephone | 860-644-2340
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Fax |
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Provider Business Mailing Address
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Address Line | 469 BUCKLAND RD STE 203
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City | SOUTH WINDSOR
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State | CT
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Zip | 06074-3737
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Country | US
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Telephone | 860-644-2340
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | DR. MICHAEL KANG
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Credential | DDS
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Telephone | 847-714-6929
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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