Provider Demographics
NPI:1063535698
Name:KONG, SUNG HYON (DDS)
Entity type:Individual
Prefix:DR
First Name:SUNG
Middle Name:HYON
Last Name:KONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11530 ALLISONVILLE RD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-1865
Mailing Address - Country:US
Mailing Address - Phone:317-845-5100
Mailing Address - Fax:317-845-5200
Practice Address - Street 1:11530 ALLISONVILLE RD
Practice Address - Street 2:SUITE 175
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-1865
Practice Address - Country:US
Practice Address - Phone:317-845-5100
Practice Address - Fax:317-845-5200
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010747A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200533220Medicaid