Provider Demographics
NPI:1972705036
Name:GAN, YAM GONG (DMD)
Entity type:Individual
Prefix:DR
First Name:YAM
Middle Name:GONG
Last Name:GAN
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 1:9524 KEARNY VILLA RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4582
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9524 KEARNY VILLA RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4582
Practice Address - Country:US
Practice Address - Phone:858-271-8850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA323041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA32304OtherSTATE LICENSE NUMBER