MEDICARE: DR. PHILIP Y. KANG DDS

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	1223P0300X	Periodontics	22DJ02278500	NJ
2	1223P0300X	Periodontics	052245	NY

General Provider Information

NPI Number	:	1992854673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP Y. KANG DDS

Provider Business Mailing Address
First Line	:	1567 PALISADE AVE
Second Line	:	#2A
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6923
Country	:	US
Telephone Number	:	201-947-8399
Fax Number	:

Provider Business Practice Location Address
First Line	:	1567 PALISADE AVE
Second Line	:	#2A
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6923
Country	:	US
Telephone Number	:	201-947-8399
Fax Number	:

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

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	08/07/2012

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