Provider Demographics
NPI:1992054787
Name:KANG, MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
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 1:509 OLIVE WAY
Mailing Address - Street 2:SUITE 1633
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101
Mailing Address - Country:US
Mailing Address - Phone:206-624-8313
Mailing Address - Fax:206-624-8922
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:SUITE 1633
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101
Practice Address - Country:US
Practice Address - Phone:206-624-8313
Practice Address - Fax:206-624-8922
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856135122300000X
WADE605674551223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN1856135OtherDENTAL LICENSURE
WADE60567455OtherWA STATE DENTAL LICENSE