Basic Information
| Provider Information | |||||||||
| NPI: | 1013297795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONG | ||||||||
| FirstName: | NAMIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20700 AVALON BLVD | ||||||||
| Address2: | |||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907463701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235642444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20700 AVALON BLVD | ||||||||
| Address2: | |||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907463701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235642444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2011 | ||||||||
| LastUpdateDate: | 11/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 64577 | CA | Y | Dental Providers | Dentist | Pediatric Dentistry | 1223G0001X | 27271 | TX | N | Dental Providers | Dentist | General Practice |
No ID Information.