Provider Demographics
NPI:1407379639
Name:KANG, TAE HYUNG (DMD)
Entity type:Individual
Prefix:
First Name:TAE HYUNG
Middle Name:
Last Name:KANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14954 NW OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-7020
Mailing Address - Country:US
Mailing Address - Phone:503-901-3558
Mailing Address - Fax:
Practice Address - Street 1:8400 NE VANCOUVER MALL LOOP
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6671
Practice Address - Country:US
Practice Address - Phone:360-450-6639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60760032122300000X
ORD10675122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty