MEDICARE: KEVIN BANG DDS, MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	056677	NY
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	A135925	CA
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	104	CA

General Provider Information

NPI Number	:	1619156551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN BANG DDS, MD

Provider Business Mailing Address
First Line	:	2520 CARLMONT DR APT 9
Second Line	:
City	:	BELMONT
State	:	CA
Zip	:	94002-3243
Country	:	US
Telephone Number	:	917-699-2815
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 HICKEY BLVD STE 403
Second Line	:
City	:	DALY CITY
State	:	CA
Zip	:	94015-2630
Country	:	US
Telephone Number	:	917-699-2815
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/29/2007
Last Update Date	:	11/30/2017

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